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Telework Pre-Application Form The purpose of the Telework loan is to provide financing for purchasing equipment related to employment, telecommuting, and/or self-employment for individuals with disabilities
This form is the first part of the loan process. Direct your questions to EquipALife program staff at 763-479-8239. All information on this form is strictly confidential and is used to determine your need for and ability to repay a loan for employment. Certain statistics are gathered to ensure the loan programs are working correctly, so we appreciate you providing as much information as possible. After you have filled in all of the information on this application, sign and return by mail to: EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, MN 55359. You may also return by email to [email protected] or by fax to 763-479- 8243. Missing information may delay a decision on your loan. If approved by EquipALife Loan Review Committee, you will be guided through the loan application process with our community banking partner.
I. Applicant Information
First Name Last Name
Social Security Number Birth Date
Address County
Address 2 Email
City, State, Zip Code Daytime Phone Number
How long have you lived at your current Evening Phone Number residence?
If you have lived at your current address for less than five years, please provide your previous address and length of residence:
Address Address 2
EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 2 City, State, Zip Code How long did you live at this residence?
II. Co-Applicant Information
First Name Last Name
______Address (only if different Address from applicant)
______City, State, Zip Code Email
([ ]) ([ ]) Daytime Phone Number Evening Phone Number
How long have you lived in your current residence?
If you have lived at your current address for less than five years, please provide your previous address and length of residence (only if different from applicant):
Address Address
______City, State, Zip Code
How long did you live at this residence?
III. Beneficiary Information (Person for whom the equipment is being purchased if different from Applicant or Co-Applicant)
First Name Last Name
Relationship to Applicant Email 3
Address Daytime Phone Number
City, State, Zip Code Evening Phone Number
IV. Applicant Financial Information
Current employer or last employer
Address Address
City, State, Zip Code Years at place of employment
Employer Phone Number Monthly Salary
Your Debt/Monthly Expenses Amount Rent/Mortgage
Property tax – if not included in mortgage
Homeowners Insurance – if not included in mortgage Auto Insurance
Health Insurance
Utilities Heat
Electricity
Phone
Cable TV
Internet
Cell phone EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 4
Other
Credit Cards: List individually
Sub total
Loan Payments Amount Monthly Balance payment owed Car loan
Student loan
Line of Credit
Other loan
Sub total
Medical Bills (List total unpaid bills that you are responsible for) Amount Creditor Monthly Balance payment owed
Sub Total
Miscellaneous: (List out all unpaid expenses of more than $500 that do not fit into a category above) Amount 5
Creditor Monthly Balance payment owed
Sub total
Your Monthly Income Source Amount (take home) Wages Net:
Social Security
Social Security Disability
Social Security Supplemental
Child Support
Other
Special Needs Trust Pension
Total Monthly Income
Your Assets Amount EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 6 Home Equity (actual)
Auto
Savings
Retirement
Personal Property
Other
Total Assets
Describe your credit history: Good
Fair
Needs Work
No History
Have you ever declared bankruptcy? Yes No (circle one)
If yes, what year? 7
Amount requested in this application form
Monthly payment you can afford
Down payment you can afford
If necessary, can you acquire a Yes No (circle one) co-signer for this loan?
V. Employment Related Equipment/Assistive Technology Devices/Services
Type of Disability
Loan Amount Requested
IMPORTANT: Submitting a business plan is preferred (if new or expanding business) Attach written quotes with detailed information about the project, prices and vendor. Remember to include the costs of evaluation, training, technical support, maintenance agreements, customization, installation, travel and any other associated costs. Please call our office before submitting your plan to ensure all the necessary paperwork is included.
A. What is your employment goal?
B. Are you currently employed? Yes No
C. Has there been a change in your employment status during the last year? Please explain.
D. What will you purchase with the loan? Attach detailed list and vendor quotes.
EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 8
E. Where will you purchase equipment? or Who will be providing home modification? 9
F. What will the equipment and/or home modification be used for?
□ Telework □ Self-Employment □ Current Employment □ New Business Development □ Volunteering
G. Where will the equipment be used?
Workforce Center Home Office Employer’s Office Other
H. How will this equipment advance your employment goal?
I. If the loan is for business start-up or expansion, do you have a business plan? Yes No
Which of the following areas will be impacted as a result of the loan and employment outcome?
□ Employment □ Independent Living □ Education/Learning □ Community Involvement □ Mobility □ Intellectual/Cognitive □ Quality of Life
K. Will this loan help increase your income and self-sufficiency?
EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 10 EquipALife’s Access to Telework Program is funded in part through a grant from the US Department of Education (75%) under the Assistive Technology Act of 1998 P.L.100-407;Technology Related Assistance to Individuals with Disabilities Act of 1998, Title III and in cooperation with A System of Technology to Achieve Results (STAR), a program of the State of Minnesota Department of Administration. VI. Additional Sources of Funding
To assist EquipALife in processing your application, please let us know if there are other financial resources available to you. In certain cases, other programs will support a portion of the cost for equipment.
EquipALife provides assistance to applicants in reviewing alternative sources of funding and works closely with county, state, insurance or other third party payer programs (for example: school districts) to combine resources for the purchase of equipment.
Is the person in need of adaptive equipment currently receiving other sources of funding?
Such as:
_____ Waiver Services (CADI /CAC/DD /TBI /ED) – (please circle the appropriate one)
_____ Vocational Rehab Services
_____ School Based Intervention – IEP or 504 Plan (what school year?)
_____ Case Management Services
_____ Grant or private source of funding to assist with purchasing needed equipment
_____ Minnesota State Family Support Grant
_____ Private Insurance Plan Name ______
_____ Other – please describe ______11
VII. Other
How did you hear about EquipALife? (Please circle)
STAR Web Search Family/Friend Newspaper/TV
Expo/Fair Flyer Yellow Pages Special Event
Other: ______
By submitting this application, the applicant claims to have provided the above information truly and accurately.
Applicant
Signature Date
Print Name
Co-applicant
Signature Date
Print Name
OPTIONAL DATA
This section is not required to receive a loan.
The following information is confidential and is only used for statistical reporting.
Individual with Disability – (Please circle one)
Sex: MALE FEMALE EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 12
Ethnicity: WHITE HISPANIC AFRICAN-AMERICAN AMERICAN INDIAN ASIAN
Other: ______
Age:
County of residence: ______
MICRO LOAN AND TELEWORK CHECKLIST SHEET
Use this checklist to assist you in completing the application process, by initialing next to each item as it is completed. Return this checklist with the application packet.
Included in the application packet:
_____ Application form
_____ Consent for Release and Exchange of Information form
_____ Tennessen Warning form
_____ EquipALife Release of Information form
_____ EquipALife Photo Release form
Additional Supporting documents to be turned in with the application:
_____ Disability verification (doctor’s statement, SSDI, etc.)
_____ Doctor’s recommendation for assistive technology (if applicable)
_____ Name and documentation of guardian (if applicable)
_____ Price quote from vendor with detailed information
_____ Income verification (2 most recent pay stubs, 2 most recent banks statements, SSI/SSDI stubs, child support, etc.) 13
_____ Most recent copy of credit report including credit score (Your credit report can be obtained for free from websites like creditkarma.com).
PLEASE NOTE THAT IF YOUR LOAN IS APPROVED YOU
HAVE 30 DAYS UNTIL THE LOAN APPROVAL EXPIRES
Consent for Release and Exchange of Information between MidCountry Bank or Klein Bank and EquipALife (formerly Assistive Technology of Minnesota)
I/we authorize MidCountry Bank or Klein Bank to release or exchange the following information with EquipALife:
My/our credit application and other information provided by me/us
Decisions made to grant/deny me/us credit
My/our payment history on EquipALife Program Loans or Bank loans, including notice of late payments
Applicant’s credit report Information
I/we understand this information may be used in determining the outcome of this loan request to EquipALife.
EquipALife is not affiliated with either MidCountry Bank or Klein Bank.
Applicant
Signature Date
Print Name
Co-applicant
EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 14
Signature Date
Print Name
BOTH MIDCOUNTRY BANK AND KLEIN BANK ARE EQUAL HOUSING LENDERS
Disability Verification
EquipALife has received disability verification from this applicant(s) which meets the requirements as set forth in the Technology Related Assistance Act of 1998, Title III.
______Signature of EquipALife Representative Date
Tennessen Warning Policy & Procedure – Section Grievance or Complaint Procedures
Subd. 2. Tennessen Warning An individual asked to supply private or confidential data concerning the individual shall be informed of: (a) the purpose and intended use of the requested data within the collecting government entity (b) whether the individual may refuse or is legally required to supply the requested data; (c) any known consequence arising from supplying or refusing to supply private or confidential data; and (d) the identity of other persons or entities authorized by state or federal law to receive the data. This requirement shall not apply when an individual is asked to supply investigative data, pursuant to section 13.82, subdivision 7, to a law enforcement officer. EquipALife is required to use this form by the State of Minnesota.
ONLY AS APPLICABLE TO THE SITUATION - Subd. 7. Criminal investigative data. Except for the data defined in subdivisions 2, 3, and 6, investigative data collected or created by a law enforcement agency in order to prepare a case against a person, 15 whether known or unknown, for the commission of a crime or other offense for which the agency has primary investigative responsibility are confidential or protected nonpublic while the investigation is active. Inactive investigative data are public unless the release of the data would jeopardize another ongoing investigation or would reveal the identity of individuals protected under subdivision 17. Photographs which are part of inactive investigative files and which are clearly offensive to common sensibilities are classified as private or nonpublic data, provided that the existence of the photographs shall be disclosed to any person requesting access to the inactive investigative file. An investigation becomes inactive upon the occurrence of any of the following events: (a) a decision by the agency or appropriate prosecutorial authority not to pursue the case; (b) expiration of the time to bring a charge or file a complaint under the applicable statute of limitations, or 30 years after the commission of the offense, whichever comes earliest; or (c) exhaustion of or expiration of all rights of appeal by a person convicted on the basis of the investigative data. Any investigative data presented as evidence in court shall be public. Data determined to be inactive under clause (a) may become active if the agency or appropriate prosecutorial authority decides to renew the investigation. During the time when an investigation is active, any person may bring an action in the district court located in the county where the data are being maintained to authorize disclosure of investigative data. The court may order that all or part of the data relating to a particular investigation be released to the public or to the person bringing the action. In making the determination as to whether investigative data shall be disclosed, the court shall consider whether the benefit to the person bringing the action or to the public outweighs any harm to the public, to the agency or to any person identified in the data. The data in dispute shall be examined by the court in camera.
Customer Signature: ______Date: ______
Applicant Release of Information
Date: Applicant Name:
I (Print Name) authorize Assistive Technology of Minnesota, Inc., doing business as EquipALife, to share the information included in my application with service providers, vendors, case managers, family members and persons involved in the review and approval of program supports. EquipALife takes great care is protecting the privacy of all customers. Individual information provided to EquipALife by an applicant for services is maintained in compliance with the provisions of all
EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 16 applicable privacy laws. The organization does not release private data unless so authorized by the applicants(s) or their legal representative.
By signing this document I acknowledge and understand the intended purpose and the need to protect my privacy rights. I understand EquipALife may use this information as needed to fulfill program obligations, for legal requirements, as mandated by federal and state oversight agencies and I understand that my signature authorizes EquipALife to disseminate the material contained in my application to involved parties for the intended purposes only. I understand that this Release of Information may be revoked at any time. I agree to provide the Release of Information to EquipALife for the specific purpose of reviewing or accessing information from third parties related to disability status, income verification, social security records, state agencies representatives, legal assistance, for product vendors and related requests from third parties as necessary to assist me.
Signature of Applicant Date
Printed Name of Applicant
Signature of Legal Guardian for minor child Date (or for adult if applicable)
Printed Name of Legal Guardian
NOTE: The applicant may require EquipALife to protect certain privacies by indicating so here. Please do not contact the following:
______17
Photo Release
I (Print Name) authorize Assistive Technology of Minnesota (ATMN), doing business as EquipALife, to use my personal data, photographs or other related private information such as stories of success, problems or concerns that I identify to increase awareness of the benefits of Assistive Technology Devices and Services. EquipALife uses customer information when authorized by this release primarily to inform the general public of their programs and services.
Signature of Applicant Date
Printed Name of Applicant
Signature of Legal Guardian for minor child Date (or for adult if applicable)
Printed Name of Legal Guardian
I understand that my signature authorizes EquipALife/ATMN to disseminate, exchange and release the material contained in my files only as the process relates to services delivered by the organization while I am a customer. Photographic information or personal stories will become the property of EquipALife/ATMN, with the customer having the option to revoke this privilege at any time. I understand this Release of Information may be revoked at any time. I agree to provide a Release of Information for specific purpose of reviewing my application for services with EquipALife/ATMN.
Privacy Statement:
EquipALife, 5563 Pioneer Creek Drive, Suite A, Maple Plain, 55359 Phone: 763.479.8239 Fax: 763-479-8243 Email: [email protected] web www.equipalife.org 18 EquipALife/ATMN will not release data on the applicant’s home address, telephone number, social security number, email or date of birth to any party without additional written consent. This agency will not release information to third parties for purposes other than stated above, does not sell customer lists or engage in membership drive actions.