Portage FSSP - Document Submissions

PORTAGE COUNTY BOARD OF DD - FAMILY SUPPORT SERVICES PROGRAM (FSSP)

DOCUMENT UPLOADS

The FSSP operates on a calendar year cycle beginning on January 1 of each year through December 31st. If you would like to review the calendar year 2024 Family Supports Stipulations, please click here and scroll down to "Portage County" and click on "Portage Forms" & then "Portage County Family Support Services Available and Program Stipulations".

Please note: To take a picture of your document(s), you must currently be completing this form on a device capable of taking pictures. If your document(s) is located on the device you are currently using, you will be able to upload it.
IF YOU NEED TO REQUEST PAYMENT OR REIMBURSEMENT, DO NOT USE THIS FORM. PLEASE CLICK HERE FOR THE REIMBURSEMENT/PAYMENT REQUEST FORM.
First Name of Child/Individual enrolled in FSSP:*
Last Name of Child/Individual enrolled in FSSP:*
Date of Birth*

MonthDayYear
Date
Parent Name*

First NameLast Name
Family Mailing Address*

Street Address (Include Apt #, Up/Down, PO box if applicable)

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
Your submission confirmation will be sent to this email address
Please upload or take a picture of your document(s). You may upload/take a picture of as many as you would like. To take a picture, you must currently be completing this form on a device capable of taking pictures:*

Cancelof
Family Signature*

Clear
Date*

YearMonthDay
Date
Should be Empty: