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New Jersey Department of Human ServicesDivision of Developmental Disabilitieshumanservices/dddGoods and Services Request Form 1110615203200058106932032443875567203097Name of Individual: DDD ID#: Date of Request: Is the requested item a good or a service? ?Good What is the good being requested? 2525233297860What entity is providing the requested good? 3078126206600Cost of requested good: 19188084445?ServiceWhat is the service being requested? 2620926250160What entity is providing the service? 26206451524001355887200660Cost of service: ? Hourly ? Weekly ? Monthly ? Annually ? One-time FeeIs the requested service a class? ? Yes ? No If “yes,” please answer the following: 2620925210126What is the title/subject of the class? 2163726199493Where does class take place? Please provide website or additional related information: 385430213601Does the entity offering the class primarily serve the general public? ? Yes ? NoIndicate one of the following:? The class is attended by the general public.? The class is attended solely by people with disabilities. If so, answer the following:Is there a comparable class offered to the general public? ?Yes ? No2982433160050How many people attend the class? 3622040152238# of hours/days individual will be in the class? 3856193173990# of hours/week this individual will be in the class? 3875566211130Is funding for this item/service available through any other entity? How would this item/service decrease the need for other services, promote community inclusion, and/or increase safety in the home? 168526010145-381025562Will this item/service benefit anyone besides the individual? 348216393330Is this item/service employment related? 245046571471524061122Related ISP outcome: 1355090-49181355651179513Request completed by: ................
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