SOCIAL SERVICES BLOCK GRANT
State Form 48203 (2-97) / DHHS 0002
Mail to: Deaf and Hard of Hearing Services Family and Social Services Administration Division of Disability, Aging, and Rehabilitative Services P.O. Box 7083 Indianapolis, IN 46207-7083
Service authorization number
Name of vendor
Name of agency / firm / organization
Name of requestor
Telephone number
Address of requestor (number and street, city, state, ZIP code)
Name of consumer(s) Date requested
Situation
Service date
Date confirmed Actual service time
Requested service time
Total service time
A.M.
P.M. to
A.M.
P.M.
A.M.
P.M. to
A.M.
P.M.
Site of service address (number and street, city, state, ZIP code)
Travel from
Travel to
Total miles (round trip)
Type of service
Name of interpreter(s) or case worker
Interpreting
County of service
Case management
Signature of authorized vendor representative
Title
Date (month, day, year)
Administrative instructions or explanations
DISTRIBUTION: White - DHHS; Canary - Contractor