RSM 3, Attachment 1400-1: Determining Consumer Financial Participation

Updated: 05/25

Completion Requirements

Prior to the purchase of any service subject to DORS financial need policy and prior to including such a service on an Individualized Plan for Employment (IPE) or Independent Living Plan (ILP), the Financial Statement (RS-5d) is used to determine whether a consumer will be required to participate financially in the cost of services over the next 12 months.

VR Program:

Completion of the Financial Statement (RS-5d) is required unless the applicant/eligible individual receives Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), based upon his or her own disability, and/or Medicaid, Temporary Cash Assistance (TCA) or Temporary Disability Assistance Program (TDAP) funding or Supplemental Nutritional Assistance Program (SNAP), due to low income. If the applicant/eligible individual receives any of these benefits, he or she may check the box in Part 1, attach benefit documentation, and then skip to complete Part 4.

ILOB Program:

Completion of this entire form is required regardless of benefits status.

Instructions

1. All services are subject to DORS financial need policy except for assessments, vocational rehabilitation guidance and counseling, interpreter services, information and referral, job-related services, personal assistance services, Pre-Employment Transition Services, and services of DORS Teachers for the blind and orientation and mobility instructor services.

2. DORS will only pay for services pre-approved and authorized in writing by a DORS official.

3. The applicant or eligible individual completes Part 1.

4. When required based on responses in Part 1, the applicant or eligible individual or financially responsible individuals identified in Part 1 will complete Part 2.

5. When Part 2 is required, the counselor completes and signs Part 3:

1. Calculate the available income by taking into consideration receipts for medical, dental, or disability-related expenses purchased by the applicant/eligible individual or by other financially responsible individuals on behalf of the applicant/eligible individual during the 12 months prior to completion of the Financial Statement (RS-5d).

2. Comparing the applicant/eligible individual/family’s available income to the ranges listed on the Annual Amount of Individual/Family Financial Participation chart​ below, taking into account the number of people dependent upon the reported income.

6. Available Income is the adjusted gross income plus any non-taxable income minus any medical and dental expenses reported on the IRS Schedule A of Form 1040, and other substantiated disability-related expenses.

   Example:

1. The number of people dependent upon the reported income is 1.

2. The individual’s Available Income is $31,725.

3. The individual/family must provide $289 per 12-month period toward the cost of services requiring financial participation.

7. Part 4 is signed by the applicant/eligible individual and, if applicable, other financially responsible persons following the determination of individual/family’s financial participation in the cost of services.

Annual Amount of Individual/Family Financial Participation

* To determine amount of individual/family participation when the available income is above $95,000, multiply the individual/family income times the percentage.

The Financial Participation Scale, included in COMAR at 13A.11.01.15, is based on the 2025 Poverty Guidelines of the U.S. Department of Health & Human Services, which are updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2).​​