Barbara Varnum, Director 1 (800) (V, TTY) (406) (local) (V, TTY

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1 Barbara Varnum, Director 1 (800) (V, TTY) (406) (local) (V, TTY

2 -INSTRUCTIONS AND INFORMATION- To qualify and be eligible to receive equipment on loan for no cost, the applicant must: 1. Be hearing, speech or mobility disabled 2. Be a resident of the state of Montana 3. Be able to demonstrate his or her ability to understand the nature and use of the equipment for the purpose of send ing and receiving messages through the telephone. 4. Meet MTAP income qualifications 5. Be 5 years of age or older Note: If the applicant is under the age of 18, a parent or legal guardian must sign and assume responsibility for the equipment. Emancipated minors are considered adults for this application. Note: Eligibility is self-certifying. However, MTAP may request additional documentation on income or verification of disability. Approval of Application: Written notification of approval will be mailed within 7 days of receipt of the application. Once the application is approved, Training is provided in home visit settings. Qualified applicants who apply to MTAP will receive the following services: Loan of specialized telephone equipment at no cost, training and education on equipment and Montana Relay services, service calls, replacement or repair of defective equipment and follow-up services. Denial of Application: If the application is denied due to the applicant not meeting the income qualifications and/or other requirements MTAP may offer a variety of services on a case by case basis. APPEAL PROCEDURES (1) To appeal any program decision specified in ARM , an applicant or recipient must submit to the program a clear written statement that the applicant or recipient is dissatisfied with the decision and wishes to appeal it. The statement must be received by the program within 60 calendar days after the date notice of the decision is given to the applicant or recipient. (a) If notice of a program decision ls given by mail, the 60-day appeal period begins to run the day after the notice is mailed. (2) Within 30 calendar days after receipt of an appeal, a representative of the program shall meet with the applicant or recipient to attempt to informally resolve the disputed matter. Within ten calendar days after this informal meeting, the program shall prepare a written summary of the issues in dispute and the proposed resolution and shall provide a copy to the applicant or recipient and the director. (3) An applicant or recipient who is not satisfied with the proposed resolution of the matter after the informal meeting may request a hearing before the committee. A hearing before the committee must be held within 90 days of the date of receipt of the request for hearing. At the hearing the applicant or recipient may: (a) be represented by legal counsel or a lay advocate; and (b) may present evidence in support of the applicant or recipient's position, including but not limited to the testimony of witnesses, documents, or other written exhibits. (4) When a recipient's loan is terminated from the program and the recipient files a timely appeal of the termination, the recipient shall be entitled to keep the equipment until the disputed matter is resolved. The matter is resolved when: (a) the recipient accepts the proposed resolution after the informal meeting; (b) the committee renders a decision after hearing; or (c) the recipient withdraws the appeal. Mail the completed application to: Montana Telecommunications Access Program PO Box 4210 Helena MT 59604

3 Montana Telecommunications Access Program (MTAP) Office Location: Mailing Address 111 North Last Chance PO. Box 4210 Gulch Suite 28 Helena, MT Helena, MT Phone Numbers and Information: MTAP Main Office Great Falls Office Helena Fax Video Phone VITTY V/TTY V /TTY This application is available online. Please visit our website for more information. address: relay@mt.gov Montana Relay is now offering Remote Conference Captioning. A free service for business meetings which allows a deaf or hard of hearing person to read what's being said. Large print versions of this document will be provided upon request. Please call , relay@mt.gov, or write to PO Box 4210, Helena, MT to request the version you need. Telecommunications Access Pro~ram Application version current as of: Feb 1st, 2016

4 For More Information Frustrating The Montana Call: Write to: MTAP PO Box 4210 Helena, MT web site: Video Phone: Phone Calls? munications Free Help from Montana Telecom- Telecommunications Access Program provides FREE: special telephone e9uipment to Montanans who 9ualit!::J. It!:JOU are hard of hearing, Dea( Deaf /ISi ind) mobilit!::j or speech disabled - or it!:jou know someone who is - please read this brochure and fill out the application inside. You might Access 9ualit!::J for Program FREE: assistive telephone e9uipment.

5 June 24, 2016 APPLICATION FOR TELECOMMUNICATIONS EQUIPMENT MTAP OFFICE USE Return to: MTAP, PO Box 4210, Helena, MT Application is: APPROVED DENIED GENERAL INFORMATION: 0 MALE 0 FEMALE REQUIRED INFORMATION MARKED WITH** ** SSN **Birthdate: j j **Name Last First MI **Street Address: Street City Zip **Mailing Address: RR, HC, PO Box City Zip * * Land Line Phone # ** Phone Service Provider: Cell Phone# Address: * * I am a Montana Resident 0Yes 0No Race: (Check all that app!yj: D American Indian or Alaska Native D Asian D Black or African American D Native Hawaiian or Pacific Islander D White Ethnicity: D Hispanic or Latino Additional Contact information: Name: Please do not list yourself Phone #: Address: City: Zip: Contact's Relationship to Applicant: How did you hear about MTAP? Newspaper Phone Company Internet Friend D Presentation D Family D TV D Phone Book Audiologist D SLP * * DISABILITY AND EQUIPMENT INFORMATION Mailing Piece D Other, Please Specify The applicant is (check all that apply): NOTE: Vision disability MUST be paired with one of the other listed disabilities to receive MTAP Services D Deaf D Hard of Hearing D Mobility Disabled D Deaf/Blind D Speech Disabled D Deaf with Cochlear Implant D Visually Disabled

6 If Mobility Disableft please describe: If Hard of Hearing or Deaf, do you wear hearing aid(s)? /one or two hearing aids List any other pertinent information regarding your disability: The applicant requests (check any that may apply): D Amplified Telephone D TTY D Artificial Larynx D Loud Ringer D Captioned Telephone D Weak Speech Amplification D "Hands Free" Speaker Phone D Light Signaler (ring flasher) D Mobile Device D I need MTAP to help me determine what equipment will work the best for me. *If you are Deaf or Speech Disabled, and are requesting and ios device, please note what device you are requesting D ipad Air D ipad Mini D iphone **INCOME INFORMATION **Total Number of Persons in Household: Please provide a DOLLAR AMOUNT for income ** Total Annual Household Gross Income$, per year Note: Participation in our program is based on household income along with the number of persons which that income supports (family size). To qualify, an applicant's family income must be lower than 250% of the current year's Federal Poverty Guidelines. VERIFIER INFORMATION The professional listed below can verify my disability: Note: Please DO NOT list yourself, a relative, your pastor or your landlord. A verifier can be any medical or hearing professional, a care-giver or social worker who can verify your hearing, speech or mobility disability. You do NOT need a signature from the verifier. **Name: Telephone: Address: ~ City: Zip: Verifier's Occupation (check one): D Licensed Physician D Voe. Rehab. Counselor D Hearing Aid Specialist D Speech Pathologist D Hearing Aid Dispenser D Audiologist D MTAP Staff D Other - Please Specify Other: 2

7 CONDITIONS OF ACCEPTANCE FOR EQUIPMENT LOAN (IF ELIGIBLE): Use and Care: The equipment is for use with the telephone and no other purpose. I agree to protect the equipment against all damage. Any defective equipment, or equipment in need of repair, will be reported to MTAP and returned to the program immediately. I will not try to repair the equipment myself, or take it apart. MTAP will replace or repair equipment for qualified consumers. Theft: If my equipment is stolen, I will report it to law enforcement within 24 hours of discovery. A copy of the theft report must be sent to MTAP within five (5) days of the date the theft was reported. Loss: If I lose my equipment, I must report the loss to MTAP. I understand that I may not be issued a replacement. Change of Address: If I move to another location within the State of Montana, I must notify the program of the new address within twenty (20) days after the date of the move. If I move out of the State of Montana, the equipment must be returned prior to the move. State Propertv: Because my equipment is the property of the State of Montana, I will not sell, give or loan the equipment to anyone. I understand that if I sell or pawn my equipment, I can be criminally prosecuted. APPLICATION CERTIFICATION I have read the above conditions of acceptance and if loaned a device, I agree to comply with all conditions. I understand my failure to comply with all of these conditions will result in my being denied the privilege of having equipment provided by the State of Montana. I certify under penalty of the offense of false swearing (Section , MCA), that I meet the definition of Deaf, Deaf /Blind, Hard of Hearing, Speech Disabled, or Motion/Mobility Disabled given on the application instruction sheet and that all statements made by me are true and correct to the best of my knowledge. I agree to inform the Montana Telecommunications Access Program (MTAP) of any changes to this information as long as I am receiving services. **Applicant's Signature: **Date: Responsible Party Signature (if applicant is unable to sign): Signature: Date Print Form Reset Form 3

8 2016 MTAP INCOME GUIDELINES (250% Federal Poverty Level) Effective 2/8/2016 #persons Monthly Income Annual Income 1 $2,475 $29,700 2 $3,337 $40,050 3 $4,200 $50,400 4 $5,062 $60,750 5 $5,925 $71,100 6 $6,787 $81,450 7 $7,652 $91,825 8 $8,519 $102,225 * Each additional person, add $4,160

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