Appendix 525-05-60

Application for Service, SFN 1047 525-05-60-05

(Revised 9/1/18 ML #3543)

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Purpose:  For individuals to formally request Home and Community Based Services (HCBS).

Prior to conducting a comprehensive assessment, an applicant (or legal representative) must complete the application form.  

• Applicant’s Name – print the name of the applicant (one SFN 1047 per applicant);
  
  
• Date – date of application;
  
  
• Agency – County Social Service Board of applicant’s physical county or HCBS Case Management agency;
  
  
• County of Residence - applicant's physical county of residents;
  
  
• I apply for services to assist me with – the applicant indicates what services or programs for which the applicant is requesting assistance;
  
  
• FOR YOUR INFORMATION – applicant or legal representative must read this section prior to signing;

• Signature section – the applicant and/or the legal representative must sign and date the application form.

The original is to be filed in the applicant’s case file

An electronic copy is available through the state e-forms (SFN 1047).