3) What are the unusual, average monthly costs that are above and beyond the typical costs faced by families with a child with a disability as a result of the burden or hardship? Itemize and describe each need. Itemize the Product or Service Average Monthly Cost for Product or Service 4) Is the family experiencing deprivation of essential needs like food, clothing, or shelter? Please give an explanation. 5) Estimate how long the deprivation or burden is likely to continue. 3-6 months 6 months -1 year 1 year or more specific date If you marked specific date, please specify here: _ ____ 6) Per Tax Return Adjusted Gross Income: $_ __ Tax Year: _ __ Estimate Current Year’s AGI (include any severance package): _ _ Please attach any additional supporting documents to this form. Examples of items to include that support your request: Divorce decree, child custody arrangement, unemployment determination, updated tax information, current pay check stubs, etc. KDADS may request additional information to consider a Fee Variance Request. The information I have given is true to the best of my knowledge. Print Name Signature/Certification Date (Mail this form to the address at the top of page 1. For additional questions, please contact KDADS at 785-296-4986.)
3) What are the unusual, average monthly costs that are above and beyond the typical costs faced by families with a child with a disability as a result of the burden or hardship? Itemize and describe each need. Itemize the Product or Service Average Monthly Cost for Product or Service 4) Is the family experiencing deprivation of essential needs like food, clothing, or shelter? Please give an explanation. 5) Estimate how long the deprivation or burden is likely to continue. 3-6 months 6 months -1 year 1 year or more specific date If you marked specific date, please specify here: _ ____ 6) Per Tax Return Adjusted Gross Income: $_ __ Tax Year: _ __ Estimate Current Year’s AGI (include any severance package): _ _ Please attach any additional supporting documents to this form. Examples of items to include that support your request: Divorce decree, child custody arrangement, unemployment determination, updated tax information, current pay check stubs, etc. KDADS may request additional information to consider a Fee Variance Request. The information I have given is true to the best of my knowledge. Print Name Signature/Certification Date (Mail this form to the address at the top of page 1. For additional questions, please contact KDADS at 785-296-4986.)
request-for-a-fee-variance-form-final875750a0172e66d690a7ff00009edf98.docx