Application For Free Special Phones

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1RETURN TO: TechOWL Free Special Phone ProgramRitter Annex 4, Room 4301301 Cecil B. Moore Av.Philadelphia, PA 19122Tel: 800-204-7428 / TTY: 711Fax: 215-204-6336 / Email: TDDP@temple.eduAPPLICATION FOR FREE SPECIAL PHONES*We highly recommend a device demonstration or loan since there is a no exchange policy.Call 800-204-7428 to schedule. I will call to schedule an equipment demonstration or loan. I do not want an equipment demonstration or loan.Do you already own equipment similar to what you are requesting from TechOWL? Yes NoIf yes, what?If yes, please check one answer below:My equipment: is broken or only works sometimes is borrowed does not meet my needs because:I will use this device at: (check one) Home School WorkAPPLICANT INFORMATION (PLEASE PRINT)Personal Information (to be completed by applicant)Name (Last)(First)(MI)Address (P.O Box not accepted)CityZipPhone ()CountyDate of Birth//EmailPerson assisting you with application, if anyRelationshipNamePhone (Email)Name of parent or guardian (for applicants under 18 years old)Name (Last)Phone ((First))Email(MI)

2APPLICANT ANNUAL INCOME AND FAMILY MEMBERSYou must attach the applicant’s most current proof of income. Examples of proof of income includeW-2’s, 1099s or award letters from retirement and/or Social Security income. If you need a copy ofyour Social Security income statement, please call 1-800-772-1213.Number of people living at this (applicant’s) address including applicant:OTHER APPLICANT INFORMATION (REQUIRED)Reason for using the Free Special Phone Program I cannot afford equipment This equipment is only available through the Free Special Phone Program I could use other programs, but the system is too complex and/or the wait is too longHow did you hear about us? friend/relative support person web presentation/exhibit by brochure/flyer other (specify)If applying for a Free Wireless Device, please complete the following questions:Do you currently subscribe to a mobile plan? Yes NoIf yes, what is the name of the mobile provider?If no, are you able to obtain a mobile plan?Have you ever used a wireless device? Yes No Yes NoPLEASE NOTE: YOU MUST GET AND MAINTAIN AN AGREEMENT WITH A MOBILE PHONECOMPANY IF YOU ARE APPLYING FOR A FREE WIRELESS DEVICE.Do you currently use any of the following types of technology? (Check all that apply): Hearing aid Cochlear Implant Speech generating device Relay (IP, VRS,TTY, STS,VCO, HCO,Captionedtelephone)OPTIONAL Black or African-American Asian or Asian-AmericanRace: American-Indian or Alaska Native Other (specify) Prefer not to answerEthnicity: Hispanic Non-HispanicGender: Female Male Other Other (List)Not applicable White or Caucasian Prefer not to answer

3APPLICANT’S STATEMENT AND SIGNATUREIMPORTANT: Submit application no later than 30 days after you have signed and dated it. I certify that all information provided on this application and supporting documents is true, completeand correct. I understand that if I purposely provide false information, I may be subject to legal action.Program officials have my permission to verify the informationprovided.I certify that I have read, understand and accept all conditions set forth in this application and havethe ability to learn to use the equipment selected. I understand that I may not sell, give, or lend toanother person any equipment provided to me by theprogram. For free wireless devices only: I will beresponsible for allservicesrelated to the equipment, includingactivation fee,monthly service plan, software and app updates, and will use the device to accessphone and telecommunications-related services, such as video relay, email and texting. I willactivate the device I receive within 30 days of receipt on a mobile service plan. If I fail to submitproof of a wireless provider plan, I may not be able to access services from TechOWL in the future.Applicant signatureDateParent/legal guardian /signature(if applicant is under 18 )Date*Demonstration Centers: If you are having trouble making a decision about which equipmentmight work for you, please contact or visit one of the Assistive Technology Regional Centers(ATRCs).You can also request a device to try out from our Lending Library.Visit: TechOWLpa.orgEmail: TDDP@temple.eduCall: 800-204-7428

4CERTIFICATION OF DISABILITYPlease print legibly or type. All information must be completed by a professional.Applicant Name(First)(Last)(MI)Please check one.I am a(n): Audiologist Optometrist Physician Ophthalmologist Speech-Language Pathologist Service Professional (public or privateagency that serves deaf, hard ofhearing and deafblind, Center forIndependent Living employee,credentialed Assistive TechnologyProfessional) Physician’s Assistant Vocational Rehabilitation Counselor Registered Nurse PractitionerPlease check the disability(ies) being certified: cognitive*o low visiono blindo deafblindo hard of hearing deafo physical*o speech*If you marked cognitive or physical disability, please explain why the applicant needs a specializedphone and/or wireless device.Certifying ProfessionalFull NameTitleAgencyPA Professional License Number, if applicableFaxPhoneEmailI certify that the applicant named above has the disability indicated, and that they require thistechnology to independently access telecommunication services.Signature of CertifierRETURN TO: TDDP@temple.eduDateOR FAX: 215-204-6336

BEFORE YOU SUBMIT YOUR APPLICATION,5READ THIS LIST AND CHECK THE BOXES TO ENSURE YOUR APPLICATION ISCOMPLETE. FAILURE TO SUBMIT ALL THE ITEMS WILL RESULT IN A DELAY. Completed application with all questions answered and all blanks filled in. Completed Disability Certification (filled out by a certifying professional). Completed Equipment Selection Sheet with one piece of equipment and/or one signaler that willwork for you.Submit photocopies of documents with the following information: Proof of PA residency with the applicant’s name and current street address (current driver’slicense, non-driver ID, utility bill, dated Social Security correspondence, copies of W-2s, schoolreport card, or other documentation pre-printed with the applicant’s name and current streetaddress). Proof of applicant’s income (Examples of proof of income include W-2’s, 1099s or award lettersfrom retirement and/or Social Security income. If you need a copy of your Social Security incomestatement, please call 1-800-772-1213). Your most recent information is required. For a free home phone: Proof of most recent telephone service bill (e.g. If you sign yourapplication in May, include the April bill.) For free wireless devices only: I will be responsible for all services related to the equipment,including activation fees, monthly service plan, software and app updates, and will use the deviceto access phone and telecommunications-related services, such as video relay, email and texting.I will activate the device I receive within 30 days of receipt on a mobile service plan. If I fail tosubmit proof of a mobile service plan, I may not be able to access services from TechOWL in thefuture.Keep a copy of your entire completed application for your records.WHAT HAPPENS NEXT? We process your application.We send you a letter saying your application is eligible, incomplete or denied.The letters come from Temple University. It is NOT a bill or junk mail.Tell us if you have changed your contact information.This whole process can take up to 4-8 weeks. Please be patient with us!TechOWLpa.orgTel: 800-204-7428Email: TDDP@temple.eduThe Free Special Phone Program (Pennsylvania’s Telecommunication Device Distribution Program) isimplemented by TechOWL, a program of the Institute on Disabilities at Temple University, in conjunction with thePA Office of Vocational Rehabilitation (OVR) and the PA Public Utility Commission (PUC).January 2022

RETURN TO: TechOWL Free Special Phone Program . 1 Ritter Annex 4, Room 430 1301 Cecil B. Moore Av. Philadelphia, PA 19122 Tel: 800-204-7428 / TTY: 711 Fax: 215-204-6336 / Email: . APPLICATION FOR FREE SPECIAL PHONES *We highly recommend a device demonstration or loan since there is a . no exchange . policy. Call 800-204-7428 to .

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