Additional Form SID
Self-Identification of Disability
Applicant – Disabled household members, NOT receiving disability cash benefits provided by the federal
government, may self-identify as disabled by reviewing and the Acts and benefits below in order to attest.
This form MUST be signed by the disabled household member or guardian.
Name of Person with Disability
Relationship of Person with Disability to Applicant
Person with Disability is any individual who is:
A handicapped individual as defined in §7(9) of the Rehabilitation Act of 1973;
Under a disability as defined in §1614(a)(3)(A) or §223(d)(1) of the Social Security Act or
in §102(7) of the Developmental Disabilities Services and Facilities Construction Act; or
Receiving benefits under 38 U.S.C. Chapter 11 or 15.
I hereby authorize the above-mentioned individual, for the purpose of confirming eligibility as a Person with
Disability, is in accordance with the above-stated definition of Person with Disability.
I certify that the above information is true and correct to the best of my knowledge and belief. If any part is false,
my participation in this agency’s program may be terminated, and I may be subject to legal action. I also
understand that the information in this application will be held in strict confidence within the agency and is
accessible to me during normal business hours.
Office Use Only
Valid:
Signature of Person with Disability or His/Her Guardian
Service Area: Williamson and Burnet Counties
604 High Tech Drive, Georgetown, TX 78626 | (512) 255-2202 | (512)763-1411 (Fax)
www.owbc-tx.org
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