You need to fill out this form if you receive specialized services.
This form identifies the resource person who will provide you with the specialized services that you need. This person must sign the form.
Print the form, fill it out, sign it and have it countersigned by the specialized resource person, then scan it. Use our Online Services to upload the completed form.
Other way to submit your document
If you are unable to submit this form digitally you can mail it to us. Print the form, fill it out, sign it, have it countersigned by the specialized resource person and mail it to the address shown on the form itself.