Free Birth to 3 Program Parental Cost Share, Parent Statement of Income - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22550 (02/2009)

STATE OF WISCONSIN

BIRTH TO 3 PROGRAM PARENTAL COST SHARE Parent Statement of Income
Use of form: This form is voluntary. Without this information, your Birth to 3 Program cannot calculate your cost share and you will be held liable for the maximum cost share. Personally identifiable information on this form is collected to determine the parental cost share and will be used only for this purpose.

I.

Family Information
Birthdate - Child (mm/dd/yyyy)

Name - Child (Last, First, MI) Address - Family (Street, City, State, Zip Code) Family Size Number of Children Who Currently Participate in Birth to 3 Program

Number of Children in Family Under Age 19 Who Have a Disability

II. Program Information
Yes No Does your child receive Medical Assistance through the Katie Beckett Program or Special Needs Adoption Subsidy? If your child receives this service, your family may have a cost share. Proceed to Section III, Financial Information. Does your child receive services through the Family Support Program? Your family will not have a cost share if you are currently paying a cost share for the Family Support Program. Proceed to Section IV, Parent Statement, providing your signature and the date signed. Check the programs or services your child / family is eligible for or currently receives. Food stamps Foster care W-2 Kinship Care Free or reduced lunch WIC (without Katie Beckett MA) SSI If you checked any of the programs above, you do not have a cost share. Please sign in Section IV. Parent Statement below.

III. Financial Information
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. IV. 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. SIGNATURE - Parent (REQUIRED) SIGNATURE - Parent (REQUIRED) Today's Date (mm/dd/yyyy) Today's Date (mm/dd/yyyy)

Parental cost share for (mm/yyyy) * To be completed at a later date.

to
(mm/yyyy)

$

= $

per month.*

V. Non-Disclosure Statement (OPTIONAL)
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. SIGNATURE - Parent (REQUIRED) SIGNATURE - Parent (REQUIRED) Today's Date (mm/dd/yyyy) Today's Date (mm/dd/yyyy)