Possibilities Grant Application

Instructions

Grant Application Checklist

Make certain to complete the grant application in its entirety. Every section must be completed. Applications that are incomplete or missing required supporting documents will NOT be accepted.

If you do not have all the information needed to complete this application, you may save and complete at a later date.

You will need to provide the following:

Copy of denial letters (if applicable) from insurance/health coverage
Copy of the most recent federal tax return form: 1040, 1040A or 1040EZ
If you are not required to file for the past year, a copy of Social Security Benefits letter or annual income.

Eligibility

Possibilities Grant dollars cannot be used to pay for devices or services purchased prior to approval of your application.

It is important that all potential forms of funding for AT have been investigated and explored before applying. Review your private health, Medicare andMedicaid insurance policies to determine what assistive technology or durable medical equipment coverage is provided.

Please Note

The Possibilities Grant is a last resort funding program, meaning all other funding sources must be used before an applicant will be considered. It also means if a certain entity is required to pay for AT, this program will not cover it. For example, AT required by law to be purchased by a school will not be funded by this grant. In addition, augmentative and alternative communication (AAC) devices will not be funded as well as they are paid for by most insurances; this includes tablets with AAC apps for communication purposes.

To be eligible, your total family/household income must fall at or under the guidelines listed in the table below:

**2024 Applicant Income Guidelines**
Number of Persons in Household	Gross Income
1	$60,240
2	$81,760
3	$103,280
4	$14,800
5	$146,320
6	$167,840

Because of this program’s limited funds, hearing aids will not be considered. We will however consider alternative hearing devices such as the Pocket Talker or Comfort Duett. For more information, please contact our office at 1.800.895.4728 and ask to speak to one of our consultants.

While there is no cap set on the amount that may be requested, but it is expected awards will not exceed $2,000. As public or private funds may only cover a portion of assistive technology costs, Possibilities Grant funds can be used in partnership to close that gap.

Background Information

Provide a good description and detail of your medical condition or disability. Be specific. Your answer helps the review committee understand the need for assistive technology.

Describe your disability to include diagnosis, severity, prognosis, and functional limitations.*

Try to paint a picture of yourself to help us understand what your disability is, how long you have had it, if it is temporary or permanent, and how it impacts your day-to-day activities. (Please be specific.)

Are you currently working with ND Assistive staff?*

Yes

No

Name of ND Assistive Staff you are working with:

Is there a Healthcare Professional who could verify your disability?*

(i.e. licensed physician, audiologist, teacher, speech language pathologist, physical therapist, occupational therapist, home health, etc.)

Yes

No

Healthcare Professional Contact Information

Name

Title

Phone

Email

Equipment and/or Training Requested

NOTE: Possibilities Grant dollars cannot be used to pay for devices or services purchased prior to approval of your application.

Include a device description, vendor information, and estimated cost (please be specific)

Device

Vendor Information

Estimated Cost

File

Max. file size: 300 MB.

If available, upload device description, vendor information, and estimated cost

Max. file size: 300 MB.

Do you think you will need training to successfully use the device(s) requested?*

Yes

No

Where do you plan on using this device(s) (i.e. school, home, work, etc.)?*

How did you determine what assistive technology was appropriate for your needs?*

Did you have a formal evaluation?*

Yes

No

Who gave you the formal evaluation?

Did you try out the requested assistive technology for a period of time or participate in a product demonstration?*

Yes

No

If yes, please explain

NOTE: If you have not had a formal evaluation or a product demonstration, please contact us at 1.800.895.4728 to schedule one. Priority will be given to those who have worked with one of our ND Assistive Technology Consultants.

Explain why this device increases your independence on a day-to-day basis (please be specific)*

Funding History

NOTE: As a reminder, this is a last resort funding program (see Grant Application Checklist for further explanation).

Have you received a Possibilities Grant in the past?*

Yes

No

Have you approached any other funding sources before seeking help from this program?*

For example: Workforce Safety and Insurance, a Medicaid Waiver, the Public School System, Vocational Rehabilitation, the Great American Bike Race, North Dakota Association for the Disabled, etc.

Yes

No

Please explain:

What Medical insurance do you currently have?*

For example: private insurance, Medicare, Medicaid, Medicaid Waivers, Workers Compensation, Veterans Administration, etc.

Is the assistive technology you are requesting funding for covered by your insurance?*

Yes

No

Please upload a copy of your denial letter

Assistive technology funding can sometimes be confusing. If you are unsure if your request is appropriate for the Possibilities Grant, please call us at 1.800.895.4728. We are happy to help you explore and understand your assistive technology funding options.

Max. file size: 300 MB.

Describe any financial circumstances that make the purchase of the requested assistive technology difficult.*

Although information about assets is not requested, those monthly or routine expenses related to disability that create financial hardship should be mentioned.

Required Income Documentation

To be eligible, your total family/household income must fall at or under the guidelines listed in the table below:

**2024 Applicant Income Guidelines**
Number of Persons in Household	Gross Income
1	$60,240
2	$81,760
3	$103,280
4	$14,800
5	$146,320
6	$167,840

Do you file Federal income taxes?*

Yes

No

Upload a copy of last year’s Federal IRS 1040 tax form(s) filed by you and members of your family/household

Max. file size: 300 MB.

To confirm your income eligibility, upload one of the following:

Evidence of your total family/household income, such as recent Social Security Administration retirement benefit statement(s); or other pension benefit statement(s).

Max. file size: 300 MB.

For the purpose of determining eligibility for the Possibilities Grant program, ND Assistive defines “income” and “household” as follows:

“Income” is all income actually received by all members of a household. This includes salary before deductions for taxes, public assistance benefits, social security payments, pensions, unemployment compensation, veteran's benefits, inheritances, alimony, child support payments, worker's compensation benefits, gifts, lottery winnings, and the like. The only exceptions are student financial aid, military housing and cost-of-living allowances, irregular income from occasional small jobs such as baby-sitting or lawn mowing, and the like.

A “household” is any individual or group of individuals who are living together at the same address as one economic unit. A household may include related and unrelated persons. An “economic unit” consists of all adult individuals contributing to and sharing in the income and expenses of a household. An adult is any person eighteen years or older. If an adult has no or minimal income, and lives with someone who provides financial support to him/her, both people shall be considered part of the same household. Children under the age of eighteen living with their parents or guardians are considered to be part of the same household as their parents or guardians.

Responsibilities and Consent Signature(s)

I agree to provide ND Assistive with my story and pictures of myself using the device(s) purchased with Possibilities Grant award funds.

Confirm

My signature below gives ND Assistive permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, stories, and the like, taken or made on behalf of my involvement with ND Assistive activities.

Confirm

The information I have provided on this application is true and complete to the best of my knowledge. If under 18 years old or under guardianship, both applicant and parent/guardian must sign.*

Confirm

I understand incomplete applications will not be considered.*

Confirm

Applicant Signature

Applicant Signature*

Please type full name

Date*

Parent/Guardian Signature (if applicable)

Parent/Guardian Signature

Please type full name

Date

Any remaining documents may be mailed, faxed, or emailed to the following:

ND Assistive
Possibilities Grant
3240 15th Street South, Suite B
Fargo, ND 58104

Fax: 701.365.6242

Email: pposey@ndassistive.org

Questions? Please call: 1.800.895.4728

Comments

This field is for validation purposes and should be left unchanged.

Instructions

Grant Application Checklist

Eligibility

Please Note

2024 Applicant Income Guidelines

Contact Information (Applicant)

Background Information

Equipment and/or Training Requested

Funding History

Required Income Documentation

2024 Applicant Income Guidelines

Responsibilities and Consent Signature(s)

Bismarck, ND

Fargo, ND

1-800-895-4728

Hours

Resources