Application for Services - Florida

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Application for Services Region/Field Office: _______ Phone #: ____________________________. Name of APD Staff Person: Date of Application : ___/___/_____. 1. Applicant Information Name: ________________________________________ ____________ SS#: * _______________________________________. (Last) (First) (MI) (Suffix). Address: ________________________________________ ___________ Medicaid #: ___________________________________. ________________________________________ ___________________ Phone #: ____________________________________. Email: ________________________________________ _____________ Alternate Phone #: ____________________________.

Application for Services Updated August 28, 2017 3 8. Citizenship Verification (must check one) (to be filled out by APD Staff):: To receive services from APD, the applicant and parent or legal guardian (if applicable) must be domiciled in Florida, and the applicant must be

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