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Application Process

Below, please find the documents needed to complete the next steps in obtaining LISS funding.

Please review the Guide thoroughly, as this will help you determine the documentation required in order to process your application.

If you have questions/concerns, please reach out to our office.  LISS@Penn-Mar.org or 877-282-8202

Selection Packet Documents

FY 21 Applicant and Family Guide

DDA LISS Program Attestation Form

Blank LISS Services and Eligibility Application

Sample LISS Services and Eligibility Application

DDA Letter of Recommendation Outline

Independent Contractor Agreement

Blank W-9 Form

Estimate Sample for Independent Contractors

LISS Documents Checklist

  • Proof of Identity including, if applicable, Parent or Legal Guardian identification (for applicants
    under the age of 21)
  • Proof of Residency
  • Proof of Developmental Disability and/or Intellectual Disability
  • Completed, Signed and Dated Attestation Form
  • LISS Services Eligibility Application
  • Invoices, Receipts or Online Printouts for Services
    • Important: When submitting your Services Eligibility Application and required documents for
      each eligible service category, you must also submit Proof of Identity (Of the Applicant and if
      applicable), Parent or Legal Guardian, Proof of Residency and Proof of a Developmental or
      Intellectual Disability, with your packet.
    • Important: For any Health or Mental Health Related services eligible for LISS Program
      funding, the invoices must indicate the license number of the professional who is licensed by the respective State of Maryland Licensing Board.
  • Health Insurance Information: Coverage or Non-coverage including Co-pay, (e.g. Explanation of
    Benefits from health insurance provider, If applicable)
  • Professional Letter of Recommendation (If applicable)
  • W-9 Form from company/independent contractor (If applicable)

If the above documents are not submitted with your application packet, your application will be delayed
as the LISS Provider waits for the required documentation. Your application will be placed with the
applications received and /or completed until the date the provider receives the documentation.

If the LISS Provider does not hear back from you after requesting additional information or does not
receive the required documents, then your application will be denied.

Submitting Documents

Documents may be submitted via mail, email, or fax.  Please use the contact information below to submit your application packet.

Penn Mar Human Services
Counties served include Allegany, Anne Arundel, Baltimore County, Baltimore City, Carroll, Frederick, Garrett, Harford, Howard, and Washington

Mailing Address:
Penn-Mar Human Services
ATTN: LISS
310 Old Freeland Road
Freeland, Maryland 21053

LISS Fax Number: 1-410-357-4767

LISS Document Submission Email: LISSApps@penn-mar.org