The Pennsylvania Assistive Technology Foundation
1004 West 9th Avenue, 1st Floor
King of Prussia, PA 19406

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PART I – ABOUT YOU / YOUR CO-APPLICANT

First Name                 MI        Last Name Jr./Sr.

Date of Birth ________/________/________ SS#_________-_____-________

Address________________________________________ Apt_____________

City _______________________________ State_________ Zip Code________

Years There _______ County_____________________________________

Telephone No. (__________)_________________________________________

Employer__________________________ Your Occupation________________

Employer’s Street Address___________________________________________

City ______________________________ State_________ Zip Code_________

Employer’s Telephone No. (____)__________ Years Employed there_________

CO-APPLICANT

First Name MI Last Name Jr./Sr.

Address ______________________________________ Apt____________

City _____________________________ State _________ Zip Code_________

Years There _______ County_______________________________

Telephone No. (_________)_________________________________________

Date of Birth ________/________/________ SS#_________-_____-_______

Employer__________________________ Your Occupation________________

Employer’s Street Address___________________________________________

City ______________________________ State_________ Zip Code_________

Employer’s Telephone No. (____)__________ Years Employed there_________

We are required to maintain statistics regarding the ethnic background of the people who will be using the assistive technology device being purchased through this application. You, however, are not required to answer these three questions. Your responses will not affect your eligibility for a loan.

Person who will be using the assistive technology device (the AT user):

1. What is the gender of the AT user?
   Male ____ Female ____
   
   
2. What is the race of the AT user? White/Caucasian ____
   Latino/Hispanic ____
   Black/African-American ____
   American Indian or Alaskan Native ____
   Native Hawaiian ____
   Pacific Islander ____
   Asian Indian ____
   Asian ____
   Other ________
   No Response ____
   
   
3. Is English the AT user's primary language?
   Yes ____    No _____
   If no, what is the primary language? ___________ 
   No response ____

PART II – DISABILITY/ASSISTIVE TECHNOLOGY INFORMATION

First Name (if not applicant) MI Last Name Jr./Sr.

Address (if different from applicant)____________________________________

___________________________________________________Apt__________

City __________________________________State_________Zip Code______

Date of Birth, if not applicant Relationship to applicant

Describe Disability.

Describe Device/Equipment/Service for which the loan is requested.

Cost of Device/Equipment/Service $___________________

Please explain how this assistive technology will improve your independence, productivity, or quality of life.

How did you determine that this is the assistive technology you need?

Evaluation by a doctor/therapist____

Recommended by (fill in)____________________________________________

Tried this device____ Other (fill in)_________________________________

Will you need training or assistance with installation, customization, or other services to begin using this assistive technology?

Yes____ No____ If yes, tell us what you will need and whether you have resources to cover these costs (can be covered by the loan).

Have you applied for any other sources of funding to purchase this assistive technology?

Yes____ No____

If yes, check all that apply and explain what happened. Please be specific.

Medical Assistance____ School District____ Vocational Rehabilitation____ Insurance____ Medicare____

Other (fill in)____________________________________________
____________________________________________

CERTIFICATION

I understand that this is a request for funds that I will need to repay with interest. I authorize the Pennsylvania Assistive Technology Foundation (PATF) to review all information provided and seek additional information from third parties required to verify the contents of this application. All information is true and correct and is provided to obtain the loan I am seeking. Any misrepresentation on any part of this application could result in rejection of this application or termination of the loan.

I further understand that issuance of a loan does not imply any type of warranty by PATF or any Lender regarding the suitability, condition, merchantability or safety of the device or equipment that I purchase with the loan. I/we understand that I/we alone are responsible for selecting the devices or equipment to be financed. Therefore, I/WE CAN MAKE NO CLAIMS AGAINST PATF OR ANY LENDER OR ANY OF THEIR AGENTS, AND I/WE EACH HEREBY RELEASE PATF AND EACH LENDER, AND ALL OF THEIR RESPECTIVE AGENTS, FROM AND AGAINST ALL LIABILITY, FOR DEFECTS IN ANY DEVICE OR EQUIPMENT OR ANY ACCIDENT OR INJURY RESULTING FROM ITS USE.

Each of us hereby also authorizes any Lender to whom PATF refers this application to disclose to PATF any information about any of us that the Lender obtains or compiles that may be relevant to decisions PATF may make with respect to the application.

________________________________ _______________

*Signature of Applicant Date

________________________________ _______________

*Signature of Co-Applicant Date

PART III – FINANCIAL INFORMATION

Gross Income $____________ Source of Income ________________

Per Week____ Month____ Year____

Other Income $____________ Source of Income _______________

Gross Income $____________ Source of Income _________________

Per Week______ Month______ Year______

Other Income $____________

Note: Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for paying this obligation.

Cash in Banks $______________ Stocks/Bonds $______________

Retirement Accounts $______________

AUTHORIZATION

Each of us understands that the information in this application will be provided to one or more lenders (each, a "Lender") in connection with our request that a Lender provide financing to support the requests described in this application.

We represent and warrant to the Pennsylvania Assistive Technology Foundation (PATF) and each Lender that all the information set forth is complete and correct in all respects. Each of us authorizes any Lender to investigate my/our credit and employment histories and to report the credit experience of any party or authorized user to my/our consumer reporting agencies and others. I (we) understand the Lender will retain this application whether or not it is approved. I (we) understand that if the information is for a loan secured by real property that additional information will be required.

I (we) understand that a Lender may require this loan to be guaranteed by the PATF. If PATF is required to guarantee this loan, I (we) authorize the PATF to investigate my employment and credit history through inquiries with third parties.

I (we) authorizes PATF to disclose the information provided in this loan application, including any health information, to the Lender for its review during the loan authorization process, with the understanding that the health information provided on this application will not adversely affect my application process in any way. In addition, I (we) authorize the PATF to disclose the information provided in this loan application, including any health information, to any other third party, such as government agencies, or auditors, to whom disclosure is necessary for the purpose of review, or oversight over the PATF's activities.

I (we) certify that each of us is 18 years old or older. At any time after this application and/or during my (our) relationship with the Lender, I (we) authorize the Lender to obtain information concerning my (our) employment and credit standing and authorize my (our) employer, banks, and/or other listed references to release any requested information to the Lender. The Lender may review from time to time my (our) eligibility for any credit extended on the account and may provide information to others. If I (we) designate other authorized users, credit bureaus may receive account information on the authorized users in each user's name. I (we) agree to notify the Lender immediately upon any material change in the information I (we) provided on the reverse side.

I (we) affirm that each of the answers given to the foregoing questions is true and correct and that the foregoing is a true and correct statement of my (our) financial position. It is a federal criminal offense to knowingly make any false statement or report, or to willfully overvalue any property for the purpose of influencing the Lender to act on this application.

________________________________ _______________

*Signature of Applicant Date

________________________________ _______________

*Signature of Co-Applicant Date

Client Information Release Authorization

I have requested that the Consumer Credit Counseling Service of Western Pennsylvania (CCCS) provide me with financial counseling in an effort to resolve the delinquency on my loan with the Pennsylvania Assistive Technology Foundation ("PATF"). I understand that I will participate in a budget and debt management counseling session that is designed to explore repayment options. I understand that CCCS and/or PATF will collect credit and income information as well as other personal financial information. I further understand that PATF and CCCS have a reciprocal agreement to share information from my credit report, budget analysis, or other personal information that is pertinent to determining payment options.

I understand that all information collected and shared between PATF and CCCS will be treated in a confidential manner and that no information about my family or me will be available to any unauthorized parties.

By signing this release, I am giving full authorization to the staffs of PATF and CCCS to collect and share the above noted information.

________________________________ _______________

*Witness Date

Pennsylvania Assistive Technology Foundation
1004 West 9th Avenue, 1st Floor
King of Prussia, PA 19406

Consumer Credit Counseling Service of Western Pennsylvania
2403 Sidney Street
Pittsburgh, PA 15203

Before mailing your application, did you…

• Attach a formal, written quote on your vendor’s company letterhead?



• Attach proof of residence and income?
  Applications cannot be processed until these are received.
  
  
  
• Acceptable proof for income includes a copy of one of the following:
  1. IRS Tax Return - ONLY - IF YOU OWN YOUR OWN BUSINESS
  2. Pay stub from Employer - ONLY - IF YOU WORK OUTSIDE THE HOME
  3. SSI Award Letter (or verification letter) / Social Security Disability Check
  
  
  
• Acceptable proof of residence includes a copy of one of the following:
  1. Driver's License
  2. Voter's registration
  3. A utility bill
  4. Non-driver's identification
     
     
     * Do not send originals
  
  
  
• Attach a detailed description of the assistive technology you need?
  
  
• Complete all parts of the application? If a question does not apply to you, be sure to put a line through it or write N/A (not applicable), so we know you did not forget to answer it.
  
  
• Sign and date the application in ink where signatures are required for applicant and co applicant?
  
  
• Fill in the amount you can afford to pay back each month?