Experiencing Emotional Distress?... Call or Text 988

Free and confidential services and help, available 24/7.

Letter of Intent for Support Coordination, Intensive Support Coordination

Please complete all required fields.

For each requested document, click Choose File, locate your file on your computer, and then click Upload. Once all files are uploaded, click the Submit button at the bottom of the page.

Accepted file formats: .txt, .rtf, .pdf, .doc, .docx, .xls, and .xlsx.

Regional map with ISC populations

Provider Name (required)

Certificate of Attendance at the most recent DD Provider Forum (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Letter of Intent form (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Service Location Addendum(s) (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Copy of Last 2 Years of Agency's Business Tax Returns or Audited Financials

2015 Business Tax Return or Audited Financials (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

2014 Business Tax Return or Audited Financials

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

To support assertions that applicant has been in business for one year.

Agency Bank Statements

February 2016 Bank Statement (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

January 2016 Bank Statement (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

December 2015 Bank Statement (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

November 2015 Bank Statement (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

October 2015 Bank Statement (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

September 2015 Bank Statement (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

For previous 6 months.

Copy of IRS Letter to Verify Tax ID (required)

Form 147C or Form CP575A
One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Copy of IRS Exempt Letter (Non-Profits Only)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

3 Professional Reference Letters

Reference Letter #1 (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Reference Letter #2 (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Reference Letter #3 (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Statement of Participation

For providers approved to operate outside the state of Georgia, submit a Statement of Participation or other documentation from the state authority that indicates the provider is in good standing.
One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Copy of DBA or Trade Name Registration

For providers who operate or will operate under a DBA or trade name, submit a copy of the DBA or trade name registration filed with the county Clerk of the Superior Court of the corporation's domicile.
One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Copy of Current GA Secretary of State Registration (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Copy of Each Site's County/City Business License or Permit

Business License or Permit #1 (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Business License or Permit #2

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Business License or Permit #3

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Business License or Permit #4

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Business License or Permit #5

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Accreditation Certificates

The Joint Commission

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

CARF

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Council on Accreditation

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Council on Quality and Leadership

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Employment Attestations

Employment Attestations - Developmental Disabilities Director (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Employment Attestations - Developmental Disabilities Professional (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Employment Attestations - Medical or Clinical Director (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Résumés

Developmental Disabilities Director Résumé (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Developmental Disabilities Professional Résumé (required)

One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.

Completed Narrative (required)

See page 7 of Letter of Intent.
One file only.
2 MB limit.
Allowed types: txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml.