Applicant Information                                                                
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( please enter medical assitance number if you do not have social security number )
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Maryland
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Applicant Representative Information: Parent, Legal Guardian, CCS or Case Worker fills out this section.
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Applicant Declaration of Intent - Please read before signing

By signing this request form, I understand I am requesting to participate in a random selection of applicants identified through documentation as having an eligible diagnosis.
I am a resident of the state of Maryland requesting funding for an eligible service as noted on the LISS website at https://dda.health.maryland.gov/Pages/liss.aspx.
I hereby attest that the information provided on this form is accurate to the best of my knowledge. I understand funding through LISS is not an entitlement and, if selected through the random selection process, I will be required to provide documentation verifying my identity, disability, residency, and an identified eligible service/item delivered or provided by an eligible vendor. I also understand that a representative of the LISS agency serving my county will contact me and assist with the LISS process.

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