Hennepin County Family Support Grant Plan
This plan covers the time period from: to
Child’s Name: __________________________ Date of Birth:_________________
Parents Name:____________________________________ Phone Number:__________________
County Case Manager: ____________________ Phone Number:
Monthly Grant Amount $_______________ Yearly Grant Amount: $
Expense Category Description of Item Cost/ ISP
month goal # Computer/software
YEARLY TOTAL $
*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
I agree that this plan relates to my child’s disability & helps them remain at
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
Client/Responsible Party Date
Approved by Case Manager Date