INDEPENDENT LIVING DEVELOPMENT ACCOUNT DESIGNATION

PURPOSE: To provide a uniform method for a claimant to designate funds as set aside for an independent living development account.

NUMBER OF COPIES AND DISPOSITION: The claimant must complete this form at any time the claimant wishes to have an account set aside as an independent living development account.

File the original in the case record and give a copy to the client. The original is a permanent part of the case record.

INSTRUCTIONS FOR COMPLETION:

The caseworker must complete the Case Name and Case Number.

The claimant (with the help of the caseworker, if necessary), must complete the remainder of the form. The claimant enters the name of the Institution holding the account, the Institution address, the type of account and the account number.

Assure that the claimant has read the form and completed it correctly. The claimant must sign and date the form. Claimants who are unable to sign may make their mark in the signature space if it is witnessed by two witnesses.

JUNE 2002