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Hennepin County Family Support Grant Plan

By Ricardo Hill,2014-06-17 17:49
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Hennepin County Family Support Grant Plan ...

    Hennepin County Family Support Grant Plan

    This plan covers the time period from: to

Child’s Name: __________________________ Date of Birth:_________________

Parents Name:____________________________________ Phone Number:__________________

Home Address:___________________________________________________________________

    County Case Manager: ____________________ Phone Number:

    Monthly Grant Amount $_______________ Yearly Grant Amount: $

    Expense Category Description of Item Cost/ ISP

    month goal # Computer/software

    Day Care

    Educational

    Medical

    Medication

    Respite Care

    Special Clothing

    Special Equipment

    Transportation

     Other

    YEARLY TOTAL $

    Reminders:

    *Specialized Diet items require a prescription from a physician and must be over and

    above the normal costs of feeding your child each month.

    *Respite purchases without a receipt must be recorded on a respite log and turned in at

    renewal. OVER

Signatures:

I agree that this plan relates to my child’s disability & helps them remain at

    home.

I understand that this plan is in effect unless and until any proposed changes are

    discussed and approved by the Family Support Grant staff.

I understand that only items/services on this approved plan can be purchased &

    receipts must be kept to verify all purchases for two years.

I understand that I am required to notify the county of any changes within 10

    days that may affect my service needs, eligibility, address or payee changes, out-

    of-home placement, etc.

I have reviewed the Family Support Grant Participation Agreement and signed

    it stating I understand my responsibilities under the Family Support Grant

    program.

______________________________________________________

    Client/Responsible Party Date

________________________________________________________

    Approved by Case Manager Date

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