Application

Address

Daytime Phone

Do you have transportation to our office? Yes No    

There must be a single party phone in your home to qualify. Do you have a single party phone in your home? Yes No

If the telephone number is not in the applicants name, please list the name of the person who is providing the service.

Have you or anyone in your household been issued any equipment from ATEL? Yes No

Are you physically able to type, if necessary? Yes No

Do you understand written language? Yes No

I communicate by (check all that apply): Speaking Lip Reading Sign Language
Other Means

Are you under 18 years of age? Yes No

If yes, please give name of parent or guardian:

I certify that I meet either of the following income qualifiers for eligibility in the program (please check one):

I receive one or more of the following*: food stamps, Medicaid, SSI, heating assistance, RiteCare, RIWorks (formerly Family Independence Program), general public assistance, RIPAE (assisting tiers 60% and 30%), or telephone lifeline service.
Our household combined annual income is below the 250% poverty line.

*You will need to have a copy of a paycheck, pension check, or documentation of eligibility
for any of the programs noted above at the time of your appointment.

I understand that this information will be kept confidential and will only be used as required for assistance, reports and audits. My signature below authorizes the ATEL program to contact my telephone carrier to verify service.

I hereby certify that all statements made by me in this application form are true and correct to the best of my knowledge and belief. As long as I am receiving services, I agree to notify the agency if there is any change of the information furnished on this form.

____________________________________ (Parent of guardian should sign if under 18 years of age.)
Signature of Applicant

___________________________
Date

Please let us know where you heard about the ATEL program.
Referred By:

_______________________________________________________________________________

Do not write below this line. For office use only.

Case Number __________ Date Received ________