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If a parent or advocate \(other than the Agency in Section 3\) is to be sent information from the DDSO, check box 3 and/or 4 and complete the appropriate parts of Section 2. Any agency in Section 3 will automatically receive information concerning the Determination. )/Type /Annot>> endobj 768 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 36.766 504.204 46.766 514.204]/StructParent 22/Subtype /Widget/T (CheckBox1[1])/TU (Put an X next to the box indicating where the information concerning the determination should be sent. If a parent or advocate \(other than the Agency in Section 3\) is to be sent information from the DDSO, check box 3 and/or 4 and complete the appropriate parts of Section 2. Any agency in Section 3 will automatically receive information concerning the Determination. )/Type /Annot>> endobj 769 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 36.769 492.908 46.769 502.908]/StructParent 23/Subtype /Widget/T (CheckBox1[2])/TU (Put an X next to the box indicating where the information concerning the determination should be sent. If a parent or advocate \(other than the Agency in Section 3\) is to be sent information from the DDSO, check box 3 and/or 4 and complete the appropriate parts of Section 2. Any agency in Section 3 will automatically receive information concerning the Determination. )/Type /Annot>> endobj 770 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 142.949 515.427 152.949 525.427]/StructParent 24/Subtype /Widget/T (CheckBox1[3])/TU (Put an X next to the box indicating where the information concerning the determination should be sent. If a parent or advocate \(other than the Agency in Section 3\) is to be sent information from the DDSO, check box 3 and/or 4 and complete the appropriate parts of Section 2. Any agency in Section 3 will automatically receive information concerning the Determination. )/Type /Annot>> endobj 771 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 36.693 481.867 46.693 491.867]/StructParent 25/Subtype /Widget/T (CheckBox1[4])/TU (Put an X next to the box indicating where the information concerning the determination should be sent. If a parent or advocate \(other than the Agency in Section 3\) is to be sent information from the DDSO, check box 3 and/or 4 and complete the appropriate parts of Section 2. Any agency in Section 3 will automatically receive information concerning the Determination. )/Type /Annot>> endobj 772 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 462.294 385.878 558.936 399.796]/StructParent 26/Subtype /Widget/T (CountryOf1[0])/TU (The parent or advocates Country)/Type /Annot>> endobj 773 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 322.362 385.492 427.51 399.41]/StructParent 27/Subtype /Widget/T (phone3[0])/TU (The parent or advocates phone number including area code. )/Type /Annot>> endobj 774 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 196.274 385.177 286.212 399.095]/StructParent 28/Subtype /Widget/T (CountryOf[0])/TU (The parent or advocates Country)/Type /Annot>> endobj 775 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 57.844 385.129 157.499 399.047]/StructParent 29/Subtype /Widget/T (phone2[0])/TU (The parent or advocates phone number including area code. )/Type /Annot>> endobj 776 0 obj <>/P 591 0 R/Parent 34 0 R/Q 1/Rect [ 520.211 401.675 556.049 415.593]/StructParent 30/Subtype /Widget/T (Sec2AZipCode[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #, zip code. Zip Code)/Type /Annot>> endobj 777 0 obj <>/Opt [ [ (NY) (NY)] [ (AL) (AL)] [ (AK) (AK)] [ (AS) (AS)] [ (AZ) (AZ)] [ (AR) (AR)] [ (CA) (CA)] [ (CO) (CO)] [ (CT) (CT)] [ (DE) (DE)] [ (DC) (DC)] [ (FM) (FM)] [ (FL) (FL)] [ (GA) (GA)] [ (GU) (GU)] [ (HI) (HI)] [ (ID) (ID)] [ (IL) (IL)] [ (IN) (IN)] [ (IA) (IA)] [ (KS) (KS)] [ (KY) (KY)] [ (LA) (LA)] [ (ME) (ME)] [ (MH) (MH)] [ (MD) (MD)] [ (MA) (MA)] [ (MI) (MI)] [ (MN) (MN)] [ (MS) (MS)] [ (MO) (MO)] [ (MT) (MT)] [ (NE) (NE)] [ (NV) (NV)] [ (NH) (NH)] [ (NJ) (NJ)] [ (NM) (NM)] [ (NY) (NY)] [ (NC) (NC)] [ (ND) (ND)] [ (MP) (MP)] [ (OH) (OH)] [ (OK) (OK)] [ (OR) (OR)] [ (PW) (PW)] [ (PA) (PA)] [ (PR) (PR)] [ (RI) (RI)] [ (SC) (SC)] [ (SD) (SD)] [ (TN) (TN)] [ (TX) (TX)] [ (UT) (UT)] [ (VT) (VT)] [ (VI) (VI)] [ (VA) (VA)] [ (WA) (WA)] [ (WV) (WV)] [ (WI) (WI)] [ (WY) (WY)]]/P 591 0 R/Parent 34 0 R/Rect [ 471.268 404.181 499.175 418.099]/StructParent 31/Subtype /Widget/T (Sec2AState1[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #, state )/Type /Annot>> endobj 778 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 313.566 402.806 439.699 416.724]/StructParent 32/Subtype /Widget/T (Sec2ACity[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #, city/town )/Type /Annot>> endobj 779 0 obj <>/P 591 0 R/Parent 34 0 R/Q 1/Rect [ 249.905 402.117 285.743 416.035]/StructParent 33/Subtype /Widget/T (Sec2ZipCode[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #, zip code. Zip Code)/Type /Annot>> endobj 780 0 obj <>/Opt [ [ (NY) (NY)] [ (AL) (AL)] [ (AK) (AK)] [ (AS) (AS)] [ (AZ) (AZ)] [ (AR) (AR)] [ (CA) (CA)] [ (CO) (CO)] [ (CT) (CT)] [ (DE) (DE)] [ (DC) (DC)] [ (FM) (FM)] [ (FL) (FL)] [ (GA) (GA)] [ (GU) (GU)] [ (HI) (HI)] [ (ID) (ID)] [ (IL) (IL)] [ (IN) (IN)] [ (IA) (IA)] [ (KS) (KS)] [ (KY) (KY)] [ (LA) (LA)] [ (ME) (ME)] [ (MH) (MH)] [ (MD) (MD)] [ (MA) (MA)] [ (MI) (MI)] [ (MN) (MN)] [ (MS) (MS)] [ (MO) (MO)] [ (MT) (MT)] [ (NE) (NE)] [ (NV) (NV)] [ (NH) (NH)] [ (NJ) (NJ)] [ (NM) (NM)] [ (NY) (NY)] [ (NC) (NC)] [ (ND) (ND)] [ (MP) (MP)] [ (OH) (OH)] [ (OK) (OK)] [ (OR) (OR)] [ (PW) (PW)] [ (PA) (PA)] [ (PR) (PR)] [ (RI) (RI)] [ (SC) (SC)] [ (SD) (SD)] [ (TN) (TN)] [ (TX) (TX)] [ (UT) (UT)] [ (VT) (VT)] [ (VI) (VI)] [ (VA) (VA)] [ (WA) (WA)] [ (WV) (WV)] [ (WI) (WI)] [ (WY) (WY)]]/P 591 0 R/Parent 34 0 R/Rect [ 202.354 402.673 230.261 416.591]/StructParent 34/Subtype /Widget/T (Sec2State1[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #, state )/Type /Annot>> endobj 781 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 50.587 401.97 173.072 415.888]/StructParent 35/Subtype /Widget/T (Sec2City[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #, city/town )/Type /Annot>> endobj 782 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 290.979 419.301 557.492 433.219]/StructParent 36/Subtype /Widget/T (PA2Name2[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #.)/Type /Annot>> endobj 783 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 29.673 419.043 290.092 432.961]/StructParent 37/Subtype /Widget/T (PA1Address2[0])/TU (The current home address of the parent or advocate . )/Type /Annot>> endobj 784 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 329.162 436.782 558.278 450.7]/StructParent 38/Subtype /Widget/T (PA2Name[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #.)/Type /Annot>> endobj 785 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 67.207 434.846 287.691 448.764]/StructParent 39/Subtype /Widget/T (PA1Address[0])/TU (The address where the parent or advocate receives mail, if different from the home address. Include the \rPO box/street/avenue, apt. #.)/Type /Annot>> endobj 786 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 342.686 451.585 558.278 465.503]/StructParent 40/Subtype /Widget/T (PA2Address[0])/TU (The parent or advocates name: Last name, first name, and middle initial. )/Type /Annot>> endobj 787 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 81.21 453.062 287.635 466.98]/StructParent 41/Subtype /Widget/T (PA1Name[0])/TU (The parent or advocates name: Last name, first name, and middle initial. )/Type /Annot>> endobj 788 0 obj <>/P 591 0 R/Parent 34 0 R/Q 1/Rect [ 520.149 300.098 555.987 314.016]/StructParent 42/Subtype /Widget/T (Sec2ZipCode[1])/TU (Indicate the address where the agency contact receives mail. Zip Code)/Type /Annot>> endobj 789 0 obj <>/Opt [ [ (NY) (NY)] [ (AL) (AL)] [ (AK) (AK)] [ (AS) (AS)] [ (AZ) (AZ)] [ (AR) (AR)] [ (CA) (CA)] [ (CO) (CO)] [ (CT) (CT)] [ (DE) (DE)] [ (DC) (DC)] [ (FM) (FM)] [ (FL) (FL)] [ (GA) (GA)] [ (GU) (GU)] [ (HI) (HI)] [ (ID) (ID)] [ (IL) (IL)] [ (IN) (IN)] [ (IA) (IA)] [ (KS) (KS)] [ (KY) (KY)] [ (LA) (LA)] [ (ME) (ME)] [ (MH) (MH)] [ (MD) (MD)] [ (MA) (MA)] [ (MI) (MI)] [ (MN) (MN)] [ (MS) (MS)] [ (MO) (MO)] [ (MT) (MT)] [ (NE) (NE)] [ (NV) (NV)] [ (NH) (NH)] [ (NJ) (NJ)] [ (NM) (NM)] [ (NY) (NY)] [ (NC) (NC)] [ (ND) (ND)] [ (MP) (MP)] [ (OH) (OH)] [ (OK) (OK)] [ (OR) (OR)] [ (PW) (PW)] [ (PA) (PA)] [ (PR) (PR)] [ (RI) (RI)] [ (SC) (SC)] [ (SD) (SD)] [ (TN) (TN)] [ (TX) (TX)] [ (UT) (UT)] [ (VT) (VT)] [ (VI) (VI)] [ (VA) (VA)] [ (WA) (WA)] [ (WV) (WV)] [ (WI) (WI)] [ (WY) (WY)]]/P 591 0 R/Parent 34 0 R/Rect [ 468.609 299.656 496.516 313.574]/StructParent 43/Subtype /Widget/T (Sec2State1[1])/TU (Indicate the address where the agency contact receives mail. Include the State)/Type /Annot>> endobj 790 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 289.069 300.682 440.836 314.6]/StructParent 44/Subtype /Widget/T (Sec2City[1])/TU (Indicate the address where the agency contact receives mail.city/town)/Type /Annot>> endobj 791 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 62.002 299.064 265.119 312.982]/StructParent 45/Subtype /Widget/T (phone2[1])/TU (The agency contacts phone number including area code and any extension. )/Type /Annot>> endobj 792 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 270.726 315.02 557.269 328.938]/StructParent 46/Subtype /Widget/T (Sec3Address[0])/TU (Indicate the address where the agency contact receives mail. Include the PO box/street, )/Type /Annot>> endobj 793 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 96.069 316.746 267.477 330.664]/StructParent 47/Subtype /Widget/T (agencyContact[0])/TU (Name of the agency staff person to be contacted regarding the eligibility determination. )/Type /Annot>> endobj 794 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 332.427 331.183 557.268 345.101]/StructParent 48/Subtype /Widget/T (Sec3Address[1])/TU (Indicate the address where the agency contact receives mail. Include the PO box/street\r zip code. )/Type /Annot>> endobj 795 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 129.183 333.003 267.477 346.921]/StructParent 49/Subtype /Widget/T (agencyCode[0])/TU (The agencys OPWDD agency code, if known. )/Type /Annot>> endobj 796 0 obj <>/P 591 0 R/Parent 34 0 R/Q 0/Rect [ 91.026 350.087 557.461 364.005]/StructParent 50/Subtype /Widget/T (agencyname[0])/TU (The agencys complete name. )/Type /Annot>> endobj 797 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 34.649 137.407 44.649 147.407]/StructParent 51/Subtype /Widget/T (CheckBoxSec41[0])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 19. PASRR Level II Assessment NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 798 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 35.295 174.124 45.295 184.124]/StructParent 52/Subtype /Widget/T (CheckBoxSec41[1])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 14. Case Management, e.g. MSC NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 799 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 35.508 156.246 45.508 166.246]/StructParent 53/Subtype /Widget/T (CheckBoxSec41[2])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 16. Art. 16 Clinic NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 800 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 35.374 209.54 45.374 219.54]/StructParent 54/Subtype /Widget/T (CheckBoxSec41[3])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 8. Day Treatment NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 801 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 34.895 192.019 44.895 202.019]/StructParent 55/Subtype /Widget/T (CheckBoxSec41[4])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 12. FET Family Education & Training NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 802 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 34.969 246.138 44.969 256.138]/StructParent 56/Subtype /Widget/T (CheckBoxSec41[5])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 2. Individualized Support Services \(ISS\) NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 803 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 34.898 227.92 44.898 237.92]/StructParent 57/Subtype /Widget/T (CheckBoxSec41[6])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 5. Community Habilitation NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 804 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 35.295 263.486 45.295 273.486]/StructParent 58/Subtype /Widget/T (CheckBoxSec41[7])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service \rthe individual is interested in receiving IF determined eligible for OPWDD services. 1. Developmental Disability Determination only No services requested at this time. NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 805 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 439.207 209.424 449.207 219.424]/StructParent 59/Subtype /Widget/T (CheckBoxSec41[8])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 11. Care at Home NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 806 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 285.688 209.155 295.688 219.155]/StructParent 60/Subtype /Widget/T (CheckBoxSec41[9])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 10. Supported Work \(SEMP\) NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 807 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 142.113 209.424 152.113 219.424]/StructParent 61/Subtype /Widget/T (CheckBoxSec41[10])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 9. Pre-Vocational services NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 808 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 437.344 227.05 447.344 237.05]/StructParent 62/Subtype /Widget/T (CheckBoxSec41[11])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 7. Day Habilitation NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 809 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 244.197 227.532 254.197 237.532]/StructParent 63/Subtype /Widget/T (CheckBoxSec41[12])/TU (Place an X in box 1 for a determination of developmental disability only. Or, place an X in the box next to each service the individual is interested in receiving IF determined eligible for OPWDD services. 6. Intermediate Care Facility \(ICF\) NOTE: The Transmittal is not an application for services. )/Type /Annot>> endobj 810 0 obj <>/N <>>>/AS /Off/BS <>/DA (/ZaDb 8.00 Tf 0 g)/F 4/FT /Btn/MK <>/P 591 0 R/Parent 34 0 R/Rect [ 357.419 245.614 367.419 255.614]/StructParent 64/Subtype /Widget/T (CheckBoxSec41[13])/TU (Place an X in box 1 for a determination of developmental disability only. 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