LISS Selected Applicants | LISS Applications

Selected Applicants

 

On this page, 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

Please refer to the Submitting Documents section at the bottom of the page for how and where to submit documents. 

 

Selection Packet Documents

Applicant and Family Guide – 2025

Blank LISS Services and Eligibility Application

Blank LISS Services and Eligibility Application – Spanish

Estimate Sample for Independent Contractor

Independent Contractor Agreement

Sample LISS Services and Eligibility Application

W-9 Form

LISS Documents Checklist

¨ Proof of Applicant Identity AND, if applicable, Parent or Legal Guardian identification (for applicants under the age of 21)
  • You must provide a copy of one of these things that has your legal first, middle, and last name. It cannot use initials or nicknames.

Provide a copy of ONE of these things. You do not need to provide more than one:

    • Valid social security card issued by the U.S. Social Security  Administration.
    • Birth certificate.
    • Valid passport issued by the U.S. Department of State.
    • A valid Permanent Resident Card (i.e., green card) or student visa, issued by the U.S. Citizenship and Immigration Services.
    • Valid military identification card issued by the U.S. Department of Defense.
    • Current driver’s license or identification card issued by the Maryland Motor Vehicle Administration.
¨ Proof of Residency
  • To qualify for the LISS Program, you must live in the state of Maryland. The documents below are proof that you live in Maryland. They must be dated within the last 12 months.

    Provide ONE of these things. You do not need to provide more than one:
    • A current bill from a utility provider. This could be your water bill or your gas and electric bill.
    • A current lease agreement.
    • A mortgage statement or proof of home ownership. This could be the deed to your home, the bill of sale, or a statement from the Maryland Department of
      Assessments and Taxation.

Please note:

If you, your parent, or your legal guardian do NOT own the place you live in, you will need to submit a statement from the owner. You will also need to provide ONE of the documents above with his or her name.

Please note: If you do not have a utility bill, lease, or mortgage information, you may provide TWO of the following documents:

    • Mail or benefits statement from a federal, state, or local government agency;
    • Checking, savings, financial account or collection agency communication;
    • MVA registration card or title;
    • Insurance car/policy;
    • Credit card statement;
    • Copy of federal or MD income tax return filing;
    • or
    • Medical or hospital bill.
¨ Proof of Developmental Disability and/or Intellectual Disability
    • To qualify for the LISS Program, you must have a developmental disability. Examples can be intellectual disability, cerebral palsy and autism. There are many others. Your disability is a physical or mental disability, or both.
    • You cannot just have a mental illness. You will probably have your disability your whole life (that means it is chronic).


      Provide ONE of these things. You do not have to submit more than one:

      • A letter written by a medical professional licensed in Maryland. This must include all of your diagnoses AND a statement that you have an intellectual or developmental disability. If the letter is not clear, the LISS Program Contractor will request additional information to prove your intellectual or developmental disability. Those will need to be completed by the medical professional.
      • An Individualized Educational Program (IEP) that has been approved within the last three years and includes the identification of an intellectual or developmental disability.
      • A letter from the Developmental Disabilities Administration (DDA) that says you are eligible for services. This is called an Eligibility Determination Letter. The Eligibility Determination Letter includes eligibility categories. The DDA eligibility categories are  developmental Disability, Supports Only, and Not Eligible.

  ¨  LISS Services Eligibility Application – Completed, signed, and dated

This is a one-page form.  Please make sure it is complete. It must be included in your application packet. It says what services or items you want to pay for with LISS Program funding. Eligible services and items can be found here.

  ¨ W-9 Form from company/independent contractor (If applicable)

  ¨   Invoices, Receipts or Online Printouts for goods or services.  Please see the glossary section (page 4) of the Applicant and Family Guide for more information.

  ¨   Proof of home ownership (for Home Modification/Barrier Removal requests)

  ¨ Independent Contractor Agreement (for services provided by an independent contractor instead of a company)

 

Please Note: 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.

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.

 

How to Video

How to complete the Services Eligibility Application:

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

Questions?

We invite you to reach out via the online contact form:

Online Contact Form

 

 

 

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