LISS Random Selection Application

Applicant's Information

To: Parents/legal guardian/Caseworkers:
When submitting a Random Selection Application on behalf of the applicant, please do not enter your demographic information (name, address, date of birth, social security etc.). It is the child and/or adult’s demographic information that must be entered into the application. If the applicant requires assistance with completing the Random Selection Application: a Vendor may help the applicant with completing the application but may not complete the application on behalf of the applicant. The applicant can also contact the LISS Program Providers to get assistance.

First name *
Middle name
Last name *
Date of birth *
Social security number *
Medical assistance number	( please enter medical assitance number if you do not have social security number )
Street address *
Address line 2
City *
State	Maryland
Zip *
County *
Telephone number (home) *
Telephone number (cell)
E-mail address *

Applicant's Representative Information: Parent, Legal Guardian, CCS, or Case Worker fills out this section.

Relationship to applicant *
Representative's name *
Telephone number *
Representative's E-mail *

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.

LISS Applicant's signature or Representative's signature if the applicant is under 18 years of age (Please type name) * Date:

LISS random selection application is not available now.

Developmental Disabilities Administration (DDA) Low Intensity Support Services (LISS) Program Random Selection Application Fiscal Year Round

Applicant Declaration of Intent - Please read before signing

Developmental Disabilities Administration (DDA)
Low Intensity Support Services (LISS) Program
Random Selection Application
Fiscal Year Round