Your Name: Date of Birth: Phone #/ Address: Today s Date: - -

Size: px
Start display at page:

Download "Your Name: Date of Birth: Phone #/Email Address: Today s Date: - -"

Transcription

1 Your Name: Date of Birth: Phone #/ Address: Today s Date: - - Name of Services Coordinator (SC) or Personal Agent (PA): SC/PA Phone # and Address: Name of Brokerage or CDDP: 1A. Select the Funding Source for Your Current ODDS services (Check All That Apply): Comprehensive Waiver K-Plan Support Services Waiver I receive state-funded services only (see directions if this is selected) Other( specify): 1B. If you do not currently receive services through an ODDS waiver, are you eligible to receive services through the Comprehensive or Support Services Waiver? (see directions if no is selected) 2A. Your Current Employment Status: Check the ODDS-funded employment service (s) that you have participated in during the last 90 days: Individual Employment Small Group Employment Employment Path Community Employment Path Facility Discovery/Career Exploration ne of the Above 2B. I am employed but do not use the applicable ODDS employment service. The applicable ODDS employment service would be: Individual Employment Small Group Employment 2C. For each service selected in 2A, provide the following information: Service Provider Name& City Contact Person s Name, Phone # & Address Discovery/Career Exploration Are You Still Receiving this Service? July 10, 2014 Page 1

2 Job Coaching Small Group Employment Employment Path Community Employment Path Facility 2D. Your Current K-Plan Services: Check the box or boxes of the following K-Plan services that you have participated in during the last 90 days: Day Support Activities Community Day Support Activities Facility Neither 2E. For each service selected in 2D, provide the following information: Service Provider Name & City Contact Person s Name, Phone # & Address Are You Still Receiving this Service? Day Support Activities Community Day Support Activities Facility July 10, 2014 Page 2

3 3. Your employment goals for your upcoming ISP year: My Annual Declaration of My Employment Goals for My ISP Year 3A. Students (age 18-20) If you are under the age of 22 and are still attending school include yourself under this category only. Attending school and do not want to work now. Expected date of exit from school: Development Plan and Vocational Assessment (CDP) will be completed: Date by which a Career Attending school and I do want to work now. Complete a CDP. 3B. Working age adults (age 21-60) must choose one of the following statements: Please read instructions for guidance on making the proper selection. If you are at least 18 years old and have exited school include yourself under this category only. Employed in an integrated employment setting and I want to: (Check all that apply. Except for Retire, complete a CDP) Retain current job Advance in current job (more hours, raise, new skills, promotion, etc.) Get a new job Get an additional job Retire I am 60 or will be 60 this ISP year. Currently unemployed and wants integrated employment. Complete a CDP. Currently unemployed and interested in integrated employment. Complete a CDP. t interested in integrated employment now but may be interested in the future. Complete a CDP. Currently unemployed and wants to retire. I am 60 or will be 60 this ISP year. Do not complete a CDP. t interested in integrated employment now and not interested in integrated employment in the future. Do not complete a CDP. Instead, complete My Decision t to Explore, Pursue, Obtain or Maintain Community Employment For My Upcoming ISP Year and in the Future and Vocational Assessment (MDE). July 10, 2014 Page 3

4 4: People who helped me to create My Declaration : My Annual Declaration of My Employment Goals for My ISP Year Printed Name Signature Role in My Life Employer (Only needed if the person is paid to provide ODDS or VR services to you) Phone # & Address X Pe rso n July 10, 2014 Page 4

5 Instructions From July 1, 2014 December 31, 2014, the My Annual Declaration of My Employment Goals for My ISP Year (My Declaration) and the accompanying My Career Development Plan and Vocational Assessment (CDP) and/or, My Decision t to Explore, Pursue, Obtain or Maintain Community Employment for My Upcoming ISP Year and in the Future and Vocational Assessment, (MDE) shall be applied to: People who are currently in a sheltered workshops; and Transition Age Youth (18-21) within 1 year of exiting High School or a High School Transition Program; and Anyone who is at least 18 and wants a CDP and is seeking integrated employment Based on the choices made in My Declaration, the individual with the assistance of their Services Coordinator (SC) or Personal Agent (PA), and others the individual wishes to be involved in this process, shall either complete a: CDP: This will help the individual and their ISP team to identify employment goals and how they will be achieved; or MDE: This will provide information about how the individual made the decision not to work and help to identify if there are other strategies to help the individual to explore, pursue, obtain or maintain employment. If an individual is 60 or will be 60 in their ISP year and they do not wish to explore, pursue, obtain or maintain community employment, they will not have to complete a CDP or MDE. If an individual is and they are still in school and do not wish to explore, pursue, obtain or maintain community employment, they will not have to complete a MDE. July 10, 2014 Page 5

6 To understand how the term employment 1 is used in My Declaration, the CDP and the MDE, please refer to the definition of an integrated employment setting from Executive Order 13-04: A setting that allows an individual to interact with non-disabled persons in the employment setting. An integrated employment setting cannot be facility-based work in a sheltered workshop or non-work activities, such as Alternatives to Employment (ATE). An integrated employment setting is a typical work environment, including self-employment or small business models, in the community. An integrated employment setting can include a group enclave or mobile crew but must allow an individual to interact with non-disabled persons in the employment setting. Funding Source: This section is important because employment services are funded through the Comprehensive Waiver and Support Services Waiver. Employment services are: Employment Path Community: Services that provide learning and work experiences, where the individual can develop general, non-job-task-specific strengths and skills that contribute to employability in integrated employment. Small Group Employment: Works with a group of 2-8 people with disabilities. Earns a wage. Discovery/Career Exploration: Developing a Discovery Profile. Initial Job Coaching: May include short term supports needed to assist the individual. This is time-limited. Ongoing Job Coaching: Ongoing Job Coaching is designed to provide support needed to assist the individual in maintaining the job long-term. Employment Path Facility: Same as Employment Path Community, except services occur in a facility setting. Job Development: is designed to obtain a job in an integrated employment setting in the general workforce for which an individual is compensated at or above the minimum wage, but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. 1 Several terms in this document refer to this term including employment, integrated employment, job, community employment and working. July 10, 2014 Page 6

7 If an individual cannot receive services through either the Comprehensive Waiver or the Support Services Waiver, they will not be able to receive any ODDS-funded employment services. For people who cannot receive services through one of these waivers, their SC or PA should refer them to other employment resources such as VR or their local Career Center. The Individual s Current Employment Status: 2A. Select the waiver-funded employment services the individual has participated in for the last 90 days because of this, multiple selections may be made. If the individual is authorized for a service but does not currently participate in it, do not select it. For example, Sam is authorized to receive initial job coaching services through the waiver. However, because he is not yet employed, he has not yet used the service, so do not select individual supported employment. Please refer to the service descriptions above when selecting services. 2B. Pertains to people who are employed but do not use the applicable ODDS employment service for support in their job. 2C. For each service selected in 2A., provide the requested information. If the individual has received the same service from more than one provider during the last 90 days, please list those providers in the applicable row. Also, indicate if the individual continues to receive this service. For example, Joe received Employment Path Community from Sertoma from 9/1/14-10/1/14. However, he chose to discontinue receiving that service from Sertoma, and began receiving the service from Impact on 10/2. Please list the information for both providers in Employment Path Community category by adding another row. The only difference would be the dates of service and that in Sertoma s row, you would check no in the last column. Please note, you are only listing both providers because Joe has received this service from both providers during the last 90 days. In 2D., make the appropriate choice. Here is a brief explanation of each service: Day Support Activities Facility (also known as n-work Facility): Person is engaged in non-work activities in a facility setting. Please note that this service is not the same as Employment Path Facility. July 10, 2014 Page 7

8 Day Support Activities Community (also known as n-work Community): Same as above but in a community setting. Neither of These Two Services: Person has not participated in either of these services in the last 90 days. For the services selected in 2D., list the requested information in the chart in 2E. Employment/Career Development This section consists of a number of choices that are designed so the individual may clearly communicate what they want to happen in regard to Employment/Career Development for their Individual Support Plan (ISP) year. It is critical that the individual understands that what they select in this section will be the basis for their employment-related supports for the upcoming ISP year. An individual may request a CDP at any time they do not have to wait for their annual ISP meeting to create or update their CDP. Additionally, per Executive Order 13-04, The provision of Employment Services by ODDS will not be delayed or denied due to the lack of a Career Development Plan. A te about Age: Some people exit high school prior to age 20 while others exit at 22. The employment /career development section is divided into two categories, each with their own age criteria. However, as stated in My Declaration, there are exceptions to the age criteria. If someone attends high school and they are 21 or 22 years old, select the Transition Age Student category. In contrast, if an individual is 18 and has exited high school, select the Working Age Adults category. Students (age 18-20) o Students: More information on when funding from ODDS can be accessed for students who are 18 and over and who are still in school is in Policy Transmittal APD-PT (Comprehensive Services) or APD-PT (Brokerage). July 10, 2014 Page 8

9 o Students who are 18 and over and still in school: If a student chooses to work, complete a CDP. If they choose not to work, nothing is required at this time, until they exit school. Within a year of exiting school a My Declaration and CDP or MDE must be completed. Working age adults (21-60) who complete the My Declaration must choose one of the following statements: Employed in integrated employment setting and wants to: If chosen, then select the applicable sub-choice (s). The individual can make multiple selections of the sub-choices. Complete a CDP. People who do not have an integrated job may choose from the following options: o Currently unemployed and wants integrated employment: The person is unemployed and knows that they want integrated employment. Complete a CDP. o Currently unemployed and interested in integrated employment: The person is unemployed and is interested in integrated employment. Complete a CDP. o t interested in integrated employment but may be interested in the future: The person does not have an integrated job and is not interested in competitive employment now but may be in the future. Complete a CDP. o Currently unemployed and wants to retire: This selection can only be made if the person is 60 or older or will be 60 in this ISP year. Do not complete a CDP. o t interested in integrated employment now and not interested in integrated employment in the future: If the person does not intend to be employed this ISP year and in the future, this must be selected. Complete a MDE. July 10, 2014 Page 9

Authorized Signature Issue Date: 6/30/2014

Authorized Signature Issue Date: 6/30/2014 Developmental Disabilities Services Policy Transmittal Patricia Baxter Number: APD-PT-14-023 Authorized Signature Issue Date: 6/30/2014 Topic: Developmental Disabilities Transmitting (check the box that

More information

Office of Developmental Disability Services (ODDS) Provider FAQ Employment Services INTRODUCTION

Office of Developmental Disability Services (ODDS) Provider FAQ Employment Services INTRODUCTION Office of Developmental Disability Services (ODDS) Provider FAQ Employment Services INTRODUCTION This Frequently Asked Questions (FAQ) document is being distributed to help clarify and facilitate the services

More information

Discovery FAQs. 1. What is Discovery?

Discovery FAQs. 1. What is Discovery? P a g e 1 Beginning July 1, 2014 the Office of Developmental Disability Services (ODDS) initiated a new service called Discovery. This FAQ is designed to answer some of the recent questions and provide

More information

Employment Outcomes for WI DVR (Updated January of 2011) (Reviewed May 2014)

Employment Outcomes for WI DVR (Updated January of 2011) (Reviewed May 2014) Vocational Rehabilitation Employment Outcomes for WI DVR (Updated January of 2011) (Reviewed May 2014) EMPLOYMENT OUTCOME = Integrated Setting + Competitive Wages ~~~~~~~~~~~ Purpose: To provide WI DVR

More information

GW HEATH Resource Center Non-Degree Postsecondary Options For Individuals with Disabilities By Mario Payne

GW HEATH Resource Center Non-Degree Postsecondary Options For Individuals with Disabilities By Mario Payne GW HEATH Resource Center Non-Degree Postsecondary Options For Individuals with Disabilities By Mario Payne HEATH Resource Center staff members field an increasing number of requests for information on

More information

SECTION III DISABILITY. A. Short-Term Disability 6 Months B. Long-Term Disability Benefits 18 Months

SECTION III DISABILITY. A. Short-Term Disability 6 Months B. Long-Term Disability Benefits 18 Months SECTION III DISABILITY A. Short-Term Disability 6 Months B. Long-Term Disability Benefits 18 Months 39 DISABILITY BENEFITS RESOURCE GUIDE Where To Call For Short-Term Disability Benefits (646) 473-9200

More information

SEMP Redesign Amendments to 14 NYCRR Subparts 635-10, 635-12 & 635-99. Proposed Regulations Effective: July 1, 2015 Comments Due: Monday, June 8, 2015

SEMP Redesign Amendments to 14 NYCRR Subparts 635-10, 635-12 & 635-99. Proposed Regulations Effective: July 1, 2015 Comments Due: Monday, June 8, 2015 Comments submitted by New York State Rehabilitation Association (NYSRA) and New York Association of Community and Residential Agencies (NYSACRA) on OPWDD Supported Employment (SEMP) Proposed Regulations

More information

UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND CONSENT DECREE

UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND CONSENT DECREE UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND UNITED STATES OF AMERICA, Case No. CA14-175 Plaintiff, v. STATE OF RHODE ISLAND, Defendant. CONSENT DECREE I. INTRODUCTION A. This Consent Decree is

More information

4100 COMMUNITY REHABILITATION PROGRAMS AND SERVICE PROVIDERS

4100 COMMUNITY REHABILITATION PROGRAMS AND SERVICE PROVIDERS 4100 COMMUNITY REHABILITATION PROGRAMS AND SERVICE PROVIDERS 4101 General. This section provides the information, guidance, and instructions most often needed by the Counselor when serving clients with

More information

Vocational Rehabilitation Services VRS

Vocational Rehabilitation Services VRS Vocational Rehabilitation Services VRS Organizational Structure Family and Social Services Administration Division of Aging Division of Mental Health & Addictions Division of Disability and Rehabilitative

More information

West Virginia Department of Health and Human Resources. Application for Child Care Services

West Virginia Department of Health and Human Resources. Application for Child Care Services West Virginia Department of Health and Human Resources Application for Child Care Services I. INSTRUCTIONS Please complete this form in order to apply for child care services. Be sure to sign and date

More information

DEFINING SUPPORT SERVICES AND SERVICE UNITS. Moving To Individualized Services and Rates

DEFINING SUPPORT SERVICES AND SERVICE UNITS. Moving To Individualized Services and Rates SECTION I: DEFINING SUPPORT SERVICES AND SERVICE UNITS This section covers: The similarities and differences between comprehensive and support services Services that a support services customer can purchase

More information

RHODE ISLAND DEPARTMENT OF HUMAN SERVICES OFFICE OF REHABILITATION SERVICES Section 115.10 POLICY AND PROCEDURES MANUAL Rev.

RHODE ISLAND DEPARTMENT OF HUMAN SERVICES OFFICE OF REHABILITATION SERVICES Section 115.10 POLICY AND PROCEDURES MANUAL Rev. I. LEGAL AUTHORITY: EMPLOYMENT Rehabilitation Act of 1973, as amended in Title IV of the Workforce Investment Act of 1998; Sections 7(11), 12(C), 100(a)(2),102(b)(3)(A) of the Act; 29 U.S.C. 705(11), 720(a)(2),

More information

This is a competitive application process, please follow directions completely.

This is a competitive application process, please follow directions completely. Opportunity Grant Scholarship 2015-2016 Supports low income students pursuing technical programs that will result in high demand, high wage occupations. This is a competitive application process, please

More information

Iowa s Employment First Initiative: Statement of Findings

Iowa s Employment First Initiative: Statement of Findings Iowa s Employment First Initiative: Statement of Findings October 2011 Contributors: Goal 1 Work Group Members SueAnn Morrow Tammara Amsbaugh LeAnn Moskowitz Casey Westhoff Maria Walker Others: Sherry

More information

CHILDCARE ASSISTANCE PROGRAMS PARENT AND PROVIDER GUIDE

CHILDCARE ASSISTANCE PROGRAMS PARENT AND PROVIDER GUIDE CHILDCARE ASSISTANCE PROGRAMS PARENT AND PROVIDER GUIDE Ramsey County Community Human Services and Think Small Contents Customer Service Standards What child care programs are available? Who should you

More information

Department of Elder Affairs Emergency Home Energy Assistance for the Elderly Program (EHEAP) Application Instructions Revised April 2014

Department of Elder Affairs Emergency Home Energy Assistance for the Elderly Program (EHEAP) Application Instructions Revised April 2014 Department of Elder Affairs Emergency Home Energy Assistance for the Elderly Program (EHEAP) Application Instructions Revised April 2014 APPLICANT S CIRTS DATA The top section of the front/first page is

More information

If the noncompliant client:

If the noncompliant client: BEM 230B 1 of 6 EMPLOYMENT-RELATED ACTIVITIES: FAP DEPARTMENT PHILOSOPHY Department of Human Services (DHS) has a unique opportunity to assist families in becoming strong, viable, participative members

More information

Injury and Illness Resource Guide

Injury and Illness Resource Guide Injury and Illness Resource Guide Getting help while you re getting better. (415) 673-4800 www.veenfirm.com A Focus on Result Have you experienced a serious injury or an illness that has caused you to

More information

R.A.G.E. Guide to 26 Questions on Options for Motorcycles

R.A.G.E. Guide to 26 Questions on Options for Motorcycles R.A.G.E. Guide to 26 Questions on Options for Motorcycles The purpose of this guide is to clarify the Options Packages and the Impacts of YOUR survey decisions. R.A.G.E. is not recommending you answer

More information

Instructions for Completing a Medicare Savings Program (MSP) Application

Instructions for Completing a Medicare Savings Program (MSP) Application Instructions for Completing a Medicare Savings Program (MSP) Application The attached Department of Human Services (DHS) Health Services Application is used to apply for Medicare Savings Programs (MSP)

More information

START-UP / USA Self-Employment Q and A: Medicaid Home and Community Based Services

START-UP / USA Self-Employment Q and A: Medicaid Home and Community Based Services START-UP / USA Self-Employment Q and A: Medicaid Home and Community Based Services Medicaid is a state-federal program that provides health care to eligible low income individuals. When states participate

More information

This Attachment represents a triennial assessment updated for the threeyear period beginning FFY 2014.

This Attachment represents a triennial assessment updated for the threeyear period beginning FFY 2014. Kansas Rehabilitation Services State Plan for Vocational Rehabilitation & Supported Employment Services Federal Fiscal Years 2014-2016 Attachment 4.11(a): Comprehensive statewide needs assessment Numerous

More information

DuPont Pension and Retirement Plan, Title I

DuPont Pension and Retirement Plan, Title I Your DuPont Benefit Resources DuPont Pension and Retirement Plan, Title I July 2008 As of July 2008, participating employers in the DuPont Pension and Retirement Plan, Title I include: E. I. du Pont de

More information

Glossary of Terms/Acronyms Used By Habilitation/Vocational Rehabilitation Funded Programs

Glossary of Terms/Acronyms Used By Habilitation/Vocational Rehabilitation Funded Programs Glossary of Terms/Acronyms Used By Habilitation/Vocational Rehabilitation Funded Programs Accessible: Refers to the client s ability to reach and utilize the services in the community if they are non ambulatory,

More information

WIOA. Implications of the new Workforce Innovation and Opportunities Act on Vocational Rehabilitation Services

WIOA. Implications of the new Workforce Innovation and Opportunities Act on Vocational Rehabilitation Services WIOA Implications of the new Workforce Innovation and Opportunities Act on Vocational Rehabilitation Services TRENDS Expanded role for VR in Transition Early involvement with Transition students Increased

More information

OREGON BULLETIN. Volume 54, No. 3 March 1, 2015. For January 16, 2015 February 15, 2015

OREGON BULLETIN. Volume 54, No. 3 March 1, 2015. For January 16, 2015 February 15, 2015 OREGON BULLETIN Supplements the 2015 Oregon Administrative Rules Compilation Volume 54, No. 3 March 1, 2015 For January 16, 2015 February 15, 2015 Published by Oregon Secretary of State Copyright 2015

More information

CMCS Informational Bulletin

CMCS Informational Bulletin DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Center for Medicaid, CHIP and Survey & Certification

More information

APSE s Concerns Over Proposed Section 511 Language and Suggested Alternatives

APSE s Concerns Over Proposed Section 511 Language and Suggested Alternatives APSE s Concerns Over Proposed Section 511 Language and Suggested Alternatives APSE would like to applaud Senator Harkin and the Senate HELP Committee for its efforts to increase the workforce participation

More information

FINANCIAL ASSISTANCE APPLICATION: COVER LETTER

FINANCIAL ASSISTANCE APPLICATION: COVER LETTER FINANCIAL ASSISTANCE APPLICATION: COVER LETTER Thank you for choosing Children s of Alabama to provide for the healthcare needs of your child. Please find attached the forms you must complete in order

More information

YES! You CAN take it with you

YES! You CAN take it with you YES! You CAN take it with you You Are Now Eligible To Convert Your Current Long-Term Disability Insurance To Disability Conversion Insurance DCI Coverage For residents of New York State Group Insurance

More information

UnitedHealthcare Plan of the River Valley, Inc. Iowa Medicaid Level of Care Guidelines. Supported Employment Individual Employment Habilitation

UnitedHealthcare Plan of the River Valley, Inc. Iowa Medicaid Level of Care Guidelines. Supported Employment Individual Employment Habilitation UnitedHealthcare Plan of the River Valley, Inc. Iowa Medicaid Level of Care Guidelines Effective Date: March, 2016 Revision Date: Supported Employment Individual Employment Habilitation Home and Community

More information

HUTCHINSON HEALTH FINANCIAL ASSISTANCE PROGRAM

HUTCHINSON HEALTH FINANCIAL ASSISTANCE PROGRAM HUTCHINSON FINANCIAL ASSISTANCE PROGRAM Thank you for your interest in Health s Financial Assistance Program. We strive to provide quality, affordable care for all of our patients and are committed to

More information

Planning for Social Security

Planning for Social Security Firm Name Team Name (if one) CPA Planner Name, Credentials Title Street Address City, NY 13160 Phone number xext # Alternate phone # address@email.com website URL Planning for Social Security Presentations

More information

REVIEW OF EMPLOYMENT SUPPORT SERVICES PROGRAMS. Report to; Governor Terence R. McAuliffe. Senator Walter A. Stosch, Co-Chair, Senate Finance Committee

REVIEW OF EMPLOYMENT SUPPORT SERVICES PROGRAMS. Report to; Governor Terence R. McAuliffe. Senator Walter A. Stosch, Co-Chair, Senate Finance Committee REVIEW OF EMPLOYMENT SUPPORT SERVICES PROGRAMS Report to; Governor Terence R. McAuliffe Senator Walter A. Stosch, Co-Chair, Senate Finance Committee Senator Charles J. Colgan, Co-Chair, Senate Finance

More information

Disability Services: Structure and Funding

Disability Services: Structure and Funding 11 Disability Services: Structure and Funding Section Purpose Provide One-Stop staff a basic understanding of the disability service structure, and various disability funding agencies, to assist them in

More information

DuPont Pension and Retirement Plan, Title I

DuPont Pension and Retirement Plan, Title I Your DuPont Benefit Resources DuPont Pension and Retirement Plan, Title I July 2013 As of July 2013, participating employers in the DuPont Pension and Retirement Plan, Title I, include: E. I. du Pont de

More information

Designing an income protection plan The Union Central Life Insurance Company DI 1071 5/07

Designing an income protection plan The Union Central Life Insurance Company DI 1071 5/07 Disability Income Insurance Client Highlights Designing an income protection plan The Union Central Life Insurance Company DI 1071 5/07 Disability Income Insurance What is your greatest asset: Your home?

More information

Retirement Plans for Small Businesses and the Self-Employed

Retirement Plans for Small Businesses and the Self-Employed Retirement Plans for Small Businesses and the Self-Employed Retirement Planning Void Just 28% of companies with 10 or fewer employees offer any type of retirement plan. 51% of companies with 10 to 24 workers

More information

MA Free and Reduced Price School Meal Application

MA Free and Reduced Price School Meal Application Student Name: School: Grade: FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE SCHOOL MEALS Dear Parent/Guardian: Children need healthy meals to learn. [Lenox Public Schools] offers healthy meals

More information

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS 1. Please read the enclosed brochure for important information. 2. You may use this application to apply for Special Care for adults

More information

FREQUENTLY ASKED QUESTIONS REGARDING THE NEW INDIVIDUAL SUPPORTED EMPLOYMENT (ISE) RATE STRUCTURE AND OTHER NEW EMPLOYMENT INCENTIVES

FREQUENTLY ASKED QUESTIONS REGARDING THE NEW INDIVIDUAL SUPPORTED EMPLOYMENT (ISE) RATE STRUCTURE AND OTHER NEW EMPLOYMENT INCENTIVES FREQUENTLY ASKED QUESTIONS REGARDING THE NEW INDIVIDUAL SUPPORTED EMPLOYMENT (ISE) RATE STRUCTURE AND OTHER NEW EMPLOYMENT INCENTIVES GENERAL QUESTIONS What is the Employment First Initiative? In order

More information

Directions for Applying for Medical Assistance and CHIP. As of May 2014

Directions for Applying for Medical Assistance and CHIP. As of May 2014 1 Directions for Applying for Medical Assistance and CHIP As of May 2014 Parents/guardians can apply for child health insurance a number of ways: calling PCCY s Child Healthwatch Helpline; using the online

More information

Second Career Questions and Answers

Second Career Questions and Answers Second Career Questions and Answers ELIGIBILITY 1. Are unemployed contract workers or seasonal workers eligible for consideration under Second Career? Individuals whose employment contract has ended are

More information

UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND COMPLAINT INTRODUCTION

UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND COMPLAINT INTRODUCTION UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND UNITED STATES OF AMERICA, Plaintiff, Case No. CA14-175 COMPLAINT v. STATE OF RHODE ISLAND, Defendant. INTRODUCTION 1. The United States of America

More information

MARYLAND YOUTH TRANSITIONAL PLAN

MARYLAND YOUTH TRANSITIONAL PLAN MARYLAND YOUTH TRANSITIONAL PLAN The Maryland Youth Transitional Plan is an ongoing planning process to ensure youth s successful transition from foster care. The following form is designed to assist a

More information

Christian Brothers Employee Retirement Plan

Christian Brothers Employee Retirement Plan 7.1.2014.SummaryPlanDescription.001018 Christian Brothers Employee Retirement Plan July 1, 2014 Christian Brothers Retirement Planning Services 1205 Windham Parkway, Romeoville, IL 60446-1679 800.807.0700

More information

Disability Income Insurance. Client Highlights. Designing an Income Protection Plan DI 1071 12/11

Disability Income Insurance. Client Highlights. Designing an Income Protection Plan DI 1071 12/11 Disability Income Insurance Client Highlights Designing an Income Protection Plan DI 1071 12/11 Disability Income Insurance What is your greatest asset: Your home? Your Business? They are both vital to

More information

Workforce Innovation and Opportunity Act (WIOA)

Workforce Innovation and Opportunity Act (WIOA) Workforce Innovation and Opportunity Act (WIOA) CSAVR/NASDSE Collaboration on the implementation of the new transition requirements in WIOA PRESENTING: Bill East, Executive Director, NASDSE Steve Wooderson,

More information

POST SCHOOL EMPLOYMENT OPPORTUNITIES

POST SCHOOL EMPLOYMENT OPPORTUNITIES POST SCHOOL OPPORTUNITIES VIII- 1 POST-SCHOOL OPPORTUNITIES COMPETITIVE APPRENTICESHIP PROGRAMS SUPPORTED DAY TRAINING / HABILITATION EXTENDED INDIVIDUAL PLACEMENT JOB SHARING MOBILE WORK CREW ENCLAVE

More information

BMO Funds State Street Bank and Trust Company Universal Individual Retirement Account Disclosure Statement. Part One: Description of Traditional IRAs

BMO Funds State Street Bank and Trust Company Universal Individual Retirement Account Disclosure Statement. Part One: Description of Traditional IRAs BMO Funds State Street Bank and Trust Company Universal Individual Retirement Account Disclosure Statement Part One: Description of Traditional IRAs Part One of the Disclosure Statement describes the rules

More information

Voluntary Short Term Disability Insurance

Voluntary Short Term Disability Insurance Voluntary Short Term Disability Insurance FOR EMPLOYEES OF THE STATE OF UTAH Answers to your questions about coverage from Standard Insurance Company STANDARD INSURANCE COMPANY About This Booklet This

More information

METHOD A ENROLLMENT FEE WAIVER

METHOD A ENROLLMENT FEE WAIVER California Community Colleges 2015-16 Board of Governors Fee Waiver Application This is an application to have your ENROLLMENT FEES WAIVED. If you need money to help with books, supplies, food, rent, transportation

More information

Post-Secondary Options

Post-Secondary Options Post-Secondary Options This informative publication ensued from the collaborative works of Family Network on Disabilities and ASAN. Family Network on Disabilities understands and respects the beliefs and

More information

Short Term Disability Insurance

Short Term Disability Insurance Short Term Disability Insurance For Employees Participating In OEBB Plans Standard Insurance Company Short Term Disability Insurance About This Brochure This brochure and the accompanying Oregon Educators

More information

St. Louis County Voluntary Long-Term Disability Insurance

St. Louis County Voluntary Long-Term Disability Insurance St. Louis County Voluntary Long-Term Disability Insurance 3 in 10 workers entering the workforce today will become disabled before retiring. 1 Are you willing to gamble with your paycheck? Why Disability

More information

Information for Workers. Information for Workers

Information for Workers. Information for Workers Information for Workers Information for Workers Revised March 2015 Contents Overview... 2 Workplace Injuries... 2 Worker Responsibilities... 2 Employer Responsibilities... 4 WCB Responsibilities... 4 Returning

More information

University of South Carolina Office of Athletics Compliance

University of South Carolina Office of Athletics Compliance University of South Carolina Office of Athletics Compliance Sports Agent/Advisor Registration Application The completion of this form is required for registration in the University of South Carolina Sports

More information

First Notice of Claim for Unemployment Benefits

First Notice of Claim for Unemployment Benefits How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Involuntary Unemployment claims - Documents required Section A: Statement of claimant

More information

Sheltered Workshops and the Subminimum Wage in North Carolina: Incentives and Accountability

Sheltered Workshops and the Subminimum Wage in North Carolina: Incentives and Accountability Sheltered Workshops and the Subminimum Wage in North Carolina: Incentives and Accountability Executive Summary The debate over sheltered workshops and the subminimum wage is part of a larger issue of the

More information

CALCULATING YOUR RETIREMENT BENEFITS

CALCULATING YOUR RETIREMENT BENEFITS CALCULATING YOUR RETIREMENT BENEFITS ET-4107 (REV 2/2015) Scan to read online. Calculating Your Retirement Benefits Eligibility... 2 Retirement Benefit Calculation Methods... 3 Annuity Payment Options...

More information

Assisting Members in Attaining Education Goals

Assisting Members in Attaining Education Goals Assisting Members in Attaining Education Goals Importance of Education and Employment o Education is often the key to financial security through employment. o Consistent with treating members like anybody

More information

Please complete in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no.

Please complete in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no. Employee Enrollment Application For 2 50 Employee Small s Virginia care plans offered by Anthem Blue Cross and Blue Shield and Keepers, Inc. PPO health care plans are insurance products offered by Anthem

More information

The College of Charleston Compliance Office. Sports Agent/Advisor Registration Application

The College of Charleston Compliance Office. Sports Agent/Advisor Registration Application The College of Charleston Compliance Office Sports Agent/Advisor Registration Application The completion of this form is required for registration in the College of Charleston Sports Agent Program. This

More information

DISTRIBUTION REQUEST FORM

DISTRIBUTION REQUEST FORM DISTRIBUTION REQUEST FORM Previously, there was little oversight regarding the withdrawal of money from 403(b) plans. The recent law changes now apply sanctions on Plans that do not carefully monitor and

More information

FIRST NAME, MIDDLE INITIAL, LAST NAME

FIRST NAME, MIDDLE INITIAL, LAST NAME SOCIAL SECURITY ADMINISTRATION TEL TOE 120/145 APPLICATION FOR DISABILITY INSURANCE BENEFITS Form Approved OMB. 0960-0060 (Do not write in this space) I apply for a period of disability and/or all insurance

More information

WHAT YOU MUST DO TO RECEIVE UNEMPLOYMENT BENEFITS

WHAT YOU MUST DO TO RECEIVE UNEMPLOYMENT BENEFITS Rev. 01/2014 Office of Unemployment Insurance Administration Unemployment Claims Unit PO Box 94094, Room 386 Baton Rouge, Louisiana 70804-9096 Unemployment Benefits Rights and Responsibilities (Benefits

More information

hy should you consider purchasing life insurance protection at your workplace?

hy should you consider purchasing life insurance protection at your workplace? W hy should you consider purchasing life insurance protection at your workplace? Employees find significant value in obtaining non-medical products in their workplace. Many of us lead busy lives and seldom

More information

Unemployment. Benefits for the unemployed

Unemployment. Benefits for the unemployed Unemployment Benefits for the unemployed Contents Unemployment 1 Benefits for the unemployed 2 When you become unemployed 2 Unemployment allowance 2 Labour market subsidy 4 Integration assistance for immigrants

More information

Your Choice Voluntary Long Term Disability Coverage Highlights Texas City of Dallas

Your Choice Voluntary Long Term Disability Coverage Highlights Texas City of Dallas Voluntary Long Term Disability Insurance Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select. Written in non-technical

More information

EMPLOYEE DISABILITY BENEFITS

EMPLOYEE DISABILITY BENEFITS For Use With Form AA-1d EMPLOYEE DISABILITY BENEFITS United States of America Railroad Retirement Board Visit our Web site at http://www.rrb.gov Form RB-1d (03-09) Table of Contents Part I - General Information

More information

GROUP LIFE INSURANCE PROGRAM. Bentley University

GROUP LIFE INSURANCE PROGRAM. Bentley University GROUP LIFE INSURANCE PROGRAM Bentley University RELIANCE STANDARD LIFE INSURANCE COMPANY Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania CERTIFICATE OF INSURANCE We certify

More information

First Notice of Claim for Unemployment Benefits

First Notice of Claim for Unemployment Benefits How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Involuntary unemployment claims - documents required Section A: Statement of claimant

More information

A GUIDE TO DISABILITY RIGHTS

A GUIDE TO DISABILITY RIGHTS A GUIDE TO DISABILITY RIGHTS TABLE OF CONTENTS 1. HOW TO USE THIS GUIDE 2. THE CLIENT ASSISTANCE PROGRAM 3. SELF-ADVOCACY SKILLS 4. WHAT IS VOCATIONAL REHABILITATION? 5. SERVICES FROM THE VOCATIONAL REHABILITATION

More information

D I S A B I L I T Y I N S U R A N C E P R O T E C T I O N

D I S A B I L I T Y I N S U R A N C E P R O T E C T I O N D I S A B I L I T Y I N S U R A N C E P R O T E C T I O N MAIN OFFICE 7800 S. Elati Street Suite 205 Littleton, Colorado 80120 303.470.5664 800.983.4448 FLORIDA OFFICE 1452 North U.S. Hwy 1 Suite 113 Most

More information

Office of Developmental Disability Services (ODDS) Provider FAQ INTRODUCTION

Office of Developmental Disability Services (ODDS) Provider FAQ INTRODUCTION Office of Developmental Disability Services (ODDS) Provider FAQ INTRODUCTION This Frequently Asked Questions (FAQ) document is developed as questions are presented to the Office of Developmental Disability

More information

Survey results from a national survey of community rehabilitation providers holding special wage certificates

Survey results from a national survey of community rehabilitation providers holding special wage certificates Journal of Vocational Rehabilitation 30 (2009) 67 85 67 DOI 10.3233/JVR-2009-0454 IOS Press Survey results from a national survey of community rehabilitation providers holding special wage certificates

More information

Three Occupational Profiles

Three Occupational Profiles Three Occupational Profiles Occupation title 1: Occupation title 2: Occupation title 3: Wages: Wages: Wages Step 1: Research 1. Choose one occupation from the Three Occupational Profiles handout. Go back

More information

WISCONSIN BUYER S GUIDE TO FIXED DEFERRED ANNUITIES

WISCONSIN BUYER S GUIDE TO FIXED DEFERRED ANNUITIES Annuity Service Center: P.O. Box 79905, Des Moines, Iowa 50325-0905 WISCONSIN BUYER S GUIDE TO FIXED DEFERRED ANNUITIES WHAT IS AN ANNUITY? An annuity is a written contract between you and a life insurance

More information

WaterSure Plus. Application form 2015/16. for customers who receive their wastewater bill from Affinity Water

WaterSure Plus. Application form 2015/16. for customers who receive their wastewater bill from Affinity Water WaterSure Plus Application form 2015/16 for customers who receive their wastewater bill from Affinity Water We understand that paying bills can be a worry, particularly for households with low incomes.

More information

Group Long Term Disability. Income Protection. For State IIA Association Members Effective July, 2001. with monthly benefits to $10,000

Group Long Term Disability. Income Protection. For State IIA Association Members Effective July, 2001. with monthly benefits to $10,000 Group Long Term Disability Income Protection with monthly benefits to $10,000 Since 1964 KELSEY NATIONAL CORPORATION With Your State IIA Endorsed Group Long Term Disability Income Protection You Get These

More information

YOUR GROUP VOLUNTARY TERM LIFE BENEFITS. Self-Insured Schools of California (SISC)

YOUR GROUP VOLUNTARY TERM LIFE BENEFITS. Self-Insured Schools of California (SISC) YOUR GROUP VOLUNTARY TERM LIFE BENEFITS Self-Insured Schools of California (SISC) Revised January 1, 2012 HOW TO OBTAIN PLAN BENEFITS To obtain benefits see the Payment of Claims provision. Forward your

More information

For Tomorrow. Connect with the Skills. O v e r v i e w. Your job is being discontinued so

For Tomorrow. Connect with the Skills. O v e r v i e w. Your job is being discontinued so O v e r v i e w Connect with the Skills For Tomorrow Providing You Job and Career Options Now As the Rapid Response team of the One-Stop Career Centers of Richland and Crawford Counties we re here to help

More information

Summary of Vocational Rehabilitation Rights: Eligibility for Services

Summary of Vocational Rehabilitation Rights: Eligibility for Services Summary of Vocational Rehabilitation Rights: Eligibility for Services A Self-Advocacy Guide 5025 E. Washington 100 North Stone Avenue Suite 202 Suite 305 Phoenix, AZ 85034-2005 Tucson, AZ 85701 602-274-6287

More information

Vocational Rehabilitation and Employment

Vocational Rehabilitation and Employment TRAINING MODULE 5 STUDY PLAN Vocational Rehabilitation and Employment Objective: To learn the elements of the VA Vocational Rehabilitation program, and what benefits and services are available for a veteran

More information

HEALTH SAVINGS ACCOUNT Q&A

HEALTH SAVINGS ACCOUNT Q&A HEALTH SAVINGS ACCOUNT Q&A HSA BASICS What is a health savings account or HSA? A health savings account (HSA) is a tax sheltered savings account, which is only offered to people who are covered under a

More information

2008-2012 $5,000 2013-2015 $5,500 Future years Increased by cost-of-living adjustments (in $500 increments)

2008-2012 $5,000 2013-2015 $5,500 Future years Increased by cost-of-living adjustments (in $500 increments) Part One of the Disclosure Statement describes the rules applicable to Traditional IRAs. IRAs described in these pages are called Traditional IRAs to distinguish them from the Roth IRAs, which are described

More information

UPMC Financial Assistance Application Information

UPMC Financial Assistance Application Information UPMC Financial Assistance Application Information UPMC offers financial assistance for medical care provided by UPMC facilities and UPMC affiliated physicians to eligible individuals and families. Based

More information

CHIP Health Insurance Renewal Form

CHIP Health Insurance Renewal Form CHIP Health Insurance Renewal Form 1. Household Information. First: MI: Last: Suffix: Head of Household : Street: Apt #: Address: Phone: City: State: Zip: Email: Primary: Alternate: Best time to call:

More information

2013-2014 SPECIAL NOTE COMPLETE ONLY ONE FORM FOR YOUR FAMILY.

2013-2014 SPECIAL NOTE COMPLETE ONLY ONE FORM FOR YOUR FAMILY. 2013-2014 SPECIAL NOTE COMPLETE ONLY ONE FORM FOR YOUR FAMILY. 1) List all household members, including all of your children in Hall County Schools, in Part 1 of this application. 2) Follow instructions

More information

Raising the Retirement Age for Social Security

Raising the Retirement Age for Social Security A October 2002 I SSUE B RIEF A MERICAN A CADEMY of A CTUARIES Raising the Retirement Age for Social Security When the Social Security program began paying monthly benefits in 1940, workers could receive

More information

Act Now! GIVE YOUR FAMILY PEAK PROTECTION. Group Long Term Disability Insurance Conversion Plan Enrollment Kit

Act Now! GIVE YOUR FAMILY PEAK PROTECTION. Group Long Term Disability Insurance Conversion Plan Enrollment Kit Act Now! You must apply within 60 days of termination GIVE YOUR FAMILY PEAK PROTECTION Group Long Term Disability Insurance Conversion Plan Enrollment Kit Customer Service Center 888-262-6873 Monday through

More information

ira individual retirement accounts Traditional IRA

ira individual retirement accounts Traditional IRA ira individual retirement accounts Traditional IRA Grow dollars for tomorrow, save on taxes today. A traditional IRA may provide you significant immediate tax savings, and due to the deferral of all taxes

More information

Disability Income Choice Portfolio

Disability Income Choice Portfolio Mutual of Omaha Insurance Company Disability Income Choice Portfolio SM MC34442 While many workers have group disability coverage through an employer, it often covers only 50 to 60 percent of their pay.

More information

MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN

MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Si necesita ayuda para llenar el formulario favor de llamar al 1-800-456-8900 Please PRINT in blue or black ink. MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Date

More information

Oregon Developmental Disabilities Services

Oregon Developmental Disabilities Services Oregon Developmental Disabilities Services STATUS REPORT Office of Developmental Disability Services Date: July 7, 2014 Project Owner: Trisha Baxter Steering Team members: Lea Ann Stutheit, Chelas Kronenberg,

More information

QUALIFIED RETIREMENT PLAN AND 403(b)(7) DISTRIBUTION REQUEST FORM

QUALIFIED RETIREMENT PLAN AND 403(b)(7) DISTRIBUTION REQUEST FORM QUALIFIED RETIREMENT PLAN AND 403(b)(7) DISTRIBUTION REQUEST FORM The Employee Retirement Income Security Act of 1974 (ERISA) requires that you receive the information contained in this form prior to your

More information

The McClatchy Company. Retirement Plan. April 1, 2009 SUMMARY PLAN DESCRIPTION. April 1, 2009. Table of Contents. Rev. 08/10

The McClatchy Company. Retirement Plan. April 1, 2009 SUMMARY PLAN DESCRIPTION. April 1, 2009. Table of Contents. Rev. 08/10 The McClatchy Company Retirement Plan April 1, 2009 SUMMARY PLAN DESCRIPTION April 1, 2009 Table of Contents Rev. 08/10 Table of Contents I. INTRODUCTION... 4 PLAN HIGHLIGHTS... 5 II. LEGACY MCCLATCHY

More information

Georgia DBHDD NOW & COMP Waiver Programs. For Self-Directing Participants

Georgia DBHDD NOW & COMP Waiver Programs. For Self-Directing Participants Public Partnerships, LLC Georgia DBHDD NOW & COMP Waiver Programs 5660 New Northside Drive Suite 450 Atlanta, Georgia 30328 Toll Free Numbers Phone: 1-866-836-6792 TTY System: 1-800-360-5899 Administrative

More information

1. What is the difference between basic and supplemental disability insurance?

1. What is the difference between basic and supplemental disability insurance? Flex FAQs Disability Insurance 1. What is the difference between basic and supplemental disability insurance? Basic disability insurance is provided at no cost to all City employees who are eligible for

More information