OCFS-4584 (10/2013)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind

APPLICATION FORM

Equipment Loan Fund for the Disabled

(Please Print or Type)

*Read the instructions on the reverse side of this form carefully. Failure to complete appropriate sections may result in rejection of the application.

SECTION I-A

1. Section I-A must be completed by the person who will be financially responsible for the loan and who is, therefore, the loan applicant.

Please check the appropriate box below signifying that the loan applicant is the:
A Disabled Person
B Parent
C Spouse
D Legal Guardian
E Individual who resides with disabled person (Specify relationship) i.e. son, daughter, brother, etc.
F Other

2. Last Name 3. First Name 4. Middle Initial

5. Birthdate 6. Social Security Number

7. Street Address 8. Home Phone No:

9. Sex: Male Female 10. Total Family Income $ 11. City

12. County 13. State 14. Zip Code

15. Name, address and phone number of nearest relative not living with you

16. Relationship

SECTION I-B

Section I-B must be completed if you checked Box B, C, D, E or F in Section I-A above. If so, please enter descriptive information about the disabled individual below. If you checked Box A in Section I-A above, then leave this section blank.

17 Last Name: 18. First Name 19. Middle Initial

20. Birthdate 21. Social Security Number

22. Street Address 23. Phone Number:

25. City 26. County 27.State 28. Zip Code

SECTION II

29. Type and description of disability:

30. Description of barrier to be overcome:

31. How will the proposed purchase assist in overcoming that barrier?

SECTION III

Equipment Vendor Completes this Section

32. Vendor's Description/Quote (Please Print or Type)

Brand Name Model Number Estimated Cost (Incl. Tax)$

TYPE OF EQUIPMENT

33. Vendor's Name 34. Street Address

35. City 36. State 37. Zip Code 38. Phone Number

39. Vendor's Signature Date:

SECTION IV

Physician Completes this Section

41. Physician's Certification (Please Print or Type)

I certify that has a disability as defined in Section 292, New York State Executive Law. (See Section IV on reverse side)

42. Diagnosis, Description of disability and functional limitations:

43. How will proposed purchase assist patient:

44. Physician's Name: 45. License Number

46. Street Address: 47. City 48. State: 49. Zip Code:

50. Phone Number: 51. Physician's Signature: 52. Date:

SECTION V

53. Loan Amount: (Note: The loan amount requested should not be less than $500 nor more than $4,000. See Section V on reverse side.)

Loan Amount Requested: $

SECTION VI

54. Loan Applicant's Certification: I certify under penalty of perjury under the laws of the United States of America and the State of New York that the information contained on this application is true and correct to the best of my knowledge, that I have attempted to obtain the described equipment through other sources of assistance (See Section VI on reverse side) and that the disabled person identified above is not eligible for nor can obtain such assistance. I authorize you to discuss my application with treating sources and vendors of the equipment I am requesting, if necessary, and also to use the information to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the program. The N.Y.S. Office of Children and Family Services has the right to request verification of the inability of the applicant to obtain funding from any other source.

55. Loan Applicant's Signature: 56. Date:

Print 3 copies, retain one copy of the application for your records. Mail two copies to the following address:

NYS Commission for the Blind,

OCFS Central Office,

52 Washington Street, South Building, Room 201,

Rensselaer, N.Y. 12144

For OCFS USE ONLY:

Date Received: Date Approved: Date Rejected:

(Mail 2 copies- NYS Commission for the Blind; Keep one copy - Your files)

INSTRUCTIONS

Introduction

The Equipment Loan Fund for the Disabled is a program which offers low interest loans for the purchase of essential equipment necessary for disabled persons to overcome barriers to daily living or vocational functioning following rehabilitation. Loan requests may be for amounts ranging from $500 to $4000. The fund was set up to help eligible New York State residents with disabilities obtain essential equipment they could not afford otherwise. Loans are available either directly to the disabled person or to the disabled person’s parent, spouse, legal guardian, individual with whom such disabled person resides, or significant other.
Essential equipment means equipment which assists the disabled person to overcome barriers associated with the disability in daily living or vocational functioning following rehabilitation. The following are some examples of equipment that come under this category: prostheses, ramps, wheelchairs, wheelchair van lifts, telecommunication devices for the deaf and hearing impaired, and devices which allow persons who are blind or visually impaired to discern printed material. (This is not an all-inclusive list and other types of equipment may qualify under this program.)
A disabled person is a person who has been certified as disabled by a New York State licensed physician or psychologist.

Instructions Overview
Sections I-A, II, V and VI are to be completed by the loan applicant. Section I-B must also be completed with information about the disabled person if he/she is not the loan applicant identified in Section I-A.
Section III is to be completed by the equipment vendor. Section IV is to be completed by a New York State licensed physician or psychologist.
NOTE: THOSE APPLICATIONS WHICH FAIL TO PROVIDE SUFFICIENT INFORMATION TO DETERMINE THE APPLICANT’S ELIGIBILITY OR WHICH SHOW THE APPLICANT TO BE INELIGIBLE WILL BE RETURNED TO THE APPLICANT BY THE LOAN ADMINISTRATOR WITH AN EXPLAINATION OF THE REASON THEY FAILED TO BE ACCEPTED.

Specific Instructions by Section

I-A Section I-A must be completed by the person who will be financially responsible for the monthly remittance of the loan. This individual may be the disabled person or the disabled person’s parent, spouse, legal guardian, individual with whom such disabled person resides, or significant other. If the applicant’s relationship to the disabled person is not described by any of the categories in boxes B thru E., check Box F and write in relationship. (If the disabled person is under the age of eighteen, a parent or legal guardian must complete and sign this loan application and is therefore the loan applicant.)
In Box No. (6) the loan applicant's Social Security Number is entered. This will assist the Office in the application process. This information will also be used should there be a need to collect monies due. Social Security Numbers, however, do not have to be provided for the application to be accepted.
In Box No. (8) enter applicant’s home phone number or a phone number at which applicant can be reached. If there is no phone number at which applicant can be reached, enter “none”.

I-B Section I-B must be completed with information about the disabled person if he/she is not the loan applicant identified in Section I-A. If the disabled person is the loan applicant, then leave this section blank.
In box No. (21) the disabled person’s Social Security Number is entered. If the disabled person does not have a Social Security Number, enter “none”.
In box Nos. (23-28), If the address of the disabled person is the same address as the loan applicant in Section I-A, write “same” in Box No. (23)

II Section II must be completed by the loan applicant giving specific answers to each of the three questions asked about the disability. If there is insufficient space, attach an additional sheet

III Section III must be completed and signed by the equipment vendor who will be selling the equipment to the loan applicant. The vendor should be a firm or corporation doing business in N.Y.S. The following information is required:
• Generic and/or brand name
• Description, if not adequately identified by generic or brand name
• Model number, if appropriate
• Cost (including sales tax)
Product brochures, if appropriate, may also be attached.

IV Section IV must be completed and signed by a physician or psychologist licensed to practice in New York State certifying the individual’s disability. Under Section 292 of the New York State Executive Law, the term “disability” means a physical mental or medical impairment resulting from anatomical, physiological or neurological conditions which prevent the exercise of a normal bodily function and which may be demonstrated by medically accepted clinical or laboratory diagnostic techniques.

V Section V must be completed by the loan applicant. Loan disbursements may be for dollar amounts ranging from a minimum amount of $500 to a maximum amount of $4,000. For example, if a piece of equipment costs $4600, the loan amount requested would be $4,000 with the remaining $600 being supplied from the individual’s personal financial resources.

VI Section VI must be signed by the loan applicant and dated. The loan applicant’s certification includes an affirmation that he/she has attempted to obtain the described equipment through other sources of assistance. Such sources of assistance include but are not limited to: other sources of credit, Federal and State programs of public assistance and vocational rehabilitation, and private assistance programs.