I swear or affirm that I have read or had read to me this entire application. I also swear or affirm, under penalty
of perjury, that all the information I have given is true, correct, and complete to the best of my ability,
knowledge and belief. I authorize the DDA to contact any person, partnership, corporation, association, or
governmental agency that has provided information about my eligibility for benefits.

Notice to Applicants:

You are providing personal information (Name, Address, Date of Birth, etc.) in this application.
The purpose of requesting this personal information is to determine your eligibility for DDA services.
If you do not provide this personal information, the DDA may deny your application. You have the
right to inspect, amend or correct this personal information. The DDA will not permit inspection of your
personal information, or make it available to others, except as permitted by federal and State laws. .

Your Responsibilities are to Provide Information and to Report Changes:

You must give true and complete information. You must provide proof of this information. We will keep it
private. We will use the social security number and other information you give us to do computer matching and
program reviews. All changes must be reported within ten (10) days. Examples of such changes include:
address, persons living in the applicant’s home, or new services or change in services from another agency.
You, your primary caregiver, legal guardian or contact person is responsible for reporting such changes. If you
intentionally do not give correct information or report changes, services may be discontinued or legal action
may be taken.

More Information about the Developmental Disabilities Administration may be found at the following website:
http://dda.health.maryland.gov
The Developmental Disabilities Administration does not discriminate on the basis of race, color, sex, national
origin, religion or disability in matters of employment or in providing access to programs.