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
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.