FAMILY INFORMATION
Child's Name:



Birth Date:



Family Size:



Number of children who currently participate in Birth to 3 Program:



Number of children under age 19 who have a disability:



PROGRAM INFORMATION
Does your child receive Medical Assistance through the Katie Beckett Program?: yes/no
If your child receives this service, your family may have a cost share.
Please proceed to Financial Information below.



Does your child receive services through the Family Support Program? yes/no
Your family will not have a cost share if you are currently paying a cost share for the Family Support Program. Please sign Parent Statement below.

Please check the programs or services your child/family is eligible for or currently receives.

• Food Stamps
• W-2
• Free or Reduced lunch
• Badger Care
• Healthy Start
• Medical Assistance (Not through Katie Beckett eligibility)
• Foster Care
• Kinship Care
• SSI
• WIC (without Katie Beckett MA)

FINANCIAL INFORMATION
Please provide your annual income*. $_________
*Annual income is the total income of the legally responsible parent(s) as reported on the parent(s)' most recent federal individual tax return.

PARENT STATEMENT
I understand that I am responsible for the cost share for services provided. If the cost share represents a financial difficulty, I can contact my Service Coordinator for a reevaluation at any time. To the best of my knowledge, the above information is an accurate statement of my current income and family status.

Parent Signature (REQUIRED)



Date



Parent Signature



Date



Parental Cost Share for ______ (Month/Year) to _______ (Month/Year) $_________ = per month

NON-DISCLOSURE STATEMENT

I have chosen not to release my financial information and agree to pay the maximum cost share of $1,800 annually or $150 per month.
Parent Signature (REQUIRED)



Date



Parent Signature



Date