Lake County DD Reimbursement Form

Lake County DD Family Support Services (FSS)/ NEON

REIMBURSEMENT REQUEST FORM
If currently enrolled in Lake County DD FSS grant program, reimbursements can be provided for many goods and services not otherwise funded by other sources and as related to the individual’s diagnosis. If you would like to view the listings of reimbursable and non-reimbursable items, please click here to go to NEON's website. Scroll down to "Lake County" and then click on "Lake Forms".

Please note: To take pictures of your receipts, you must currently be completing this form on a device capable of taking pictures. If your receipts are located on the device you are currently using, you will be able to upload them.
First Name of Child/Individual enrolled in FSS*
Last Name of Child/Individual enrolled in FSS*
Date of Birth of Child/Individual enrolled in FSS*

MonthDayYear
Date
Parent/Guardian First NameParent/Guardian Last Name
Address*

Street Address (Include Apt #, Up/down, PO Box, etc)

Street Address Line 2

CityState

Zip Code
Will reimbursement check be made payable to Parent/Guardian listed above?:*

YesNo
Please list the name of the individual to be reimbursed (full name of person the check should be made payable to):*

First NameLast Name
Address where check is to be delivered:*

Same as Parent/GuardianOther
Address where check is to be delivered:*

Street Address - Include Apt #, PO Box, etc.

Street Address Line 2

CityState

Zip Code
Parent/Guardian E-mail*
example@example.com
Parent/Guardian Phone *
Please select all categories you are submitting for reimbursement:*

RespiteIncontinence SuppliesCampSpecial DietCounseling/Therapy/EducationEquipmentOther (ie. memberships, guardianship fees, etc)
Respite Total:*
Incontinence Supplies Total:*
Camp Total:*
Special Diet Total:*
Counseling/Therapy/Education Total:*
Equipment Total:*
Other (ie. memberships, guardianship fees) Total:*
Total Amount:
This amount will auto calculate
1Total Amount:
If uploading a store receipt, the date of purchase MUST be included in the photo. Any items you wish to be reimbursed for must be clearly marked on the receipt.

If uploading counseling/therapy/education receipts, the receipts must include the date(s) of service and the individual's name who is receiving Family Supports funding.
Please click below to upload OR take a picture of your receipt(s). There is no limit to the number of uploads/pictures. To take a picture, you must currently be completing this form on a device capable of taking pictures: *

Cancelof
I understand that I must CLEARLY IDENTIFY which item(s) on the receipt(s) being submitted are to be reimbursed
Additional Comments (if any):

0/100
Signature:*

Clear
Submission Date*

YearMonthDay
Date
Should be Empty:

Lake County DD Family Support Services (FSS)/ NEON