Home > iCanConnect: Deaf-Blind Service > iCanConnect Application iCanConnect:Application "*" indicates required fields Step 1 of 6 16% Instructions and Guidelines Overview The National Deaf-Blind Equipment Distribution Program (NDBEDP) supports local programs that distribute equipment to low-income individuals who are deaf-blind (have combined hearing and vision loss) to enable access to telephone, advanced communications, and information services. This support was mandated by the Twenty-First Century Communications and Video Accessibility Act of 2010 (CVAA) and is provided by the Federal Communications Commission (FCC). For more information about the NDBEDP, please visit http://icanconnect.org or http://www.fcc.gov/ndbedp. Who is eligible to receive equipment? Under the CVAA, only low-income individuals who are deaf-blind are eligible to receive equipment provided through the NDBEDP. Applicants must provide verification of their status as low-income and deaf-blind. Income Eligibility To be eligible, your total family/household income must be below 400% of the Federal Poverty Guidelines, as shown in the following table: 2021 Federal Poverty Guidelines Number of persons in family/ household 400% (except Alaska and Hawaii) 400% for Alaska 400% for Hawaii 1 $51,520 $64,360 $59,280 2 $69,680 $87,080 $80,160 3 $87,840 $109,800 $101,040 4 $106,000 $132,520 $121,920 5 $124,160 $155,240 $142,800 6 $142,320 $177,960 $163,680 7 $160,480 $2000,680 $184,560 8 $178,400 $223,400 $205,440 For each additional person, add $18,160 $22,720 $20,880 Source: U.S. Department of Health and Human Services For purposes of determining income eligibility for the NDBEDP, the FCC 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. Disability Eligibility For this program, the CVAA requires that the term "deaf-blind" has the same meaning given by the Helen Keller National Center Act. In general, the individual must have a certain vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working). Specifically, the FCC’s NDBEDP rule 64.6203(c) states that an individual who is “deaf-blind” is: Any individual: Who has a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions: Who has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and For whom the combination of impairments described in (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation. An individual’s functional abilities with respect to using Telecommunications service, Internet access service, and advanced communications services, including interexchange services and advanced telecommunications and information services in various environments shall be considered when determining whether the individual is deaf-blind under (ii) and (iii) of this section. The definition in this paragraph (c) also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives. Who can attest to a person’s disability eligibility? A practicing professional who has direct knowledge of the person's vision and hearing loss, such as: Audiologist Community-based service provider Educator Hearing professional HKNC representative Medical/health professional School for the deaf and/or blind Specialist in Deaf-Blindness Speech pathologist State equipment/assistivetechnology program Vision professional Vocational rehabilitation counsellor Such professionals may also include, in the attestation, information about the individual’s functional abilities to use telecommunications, Internet access, and advanced communications services in various settings. Existing documentation that a person is deaf-blind, such as an individualized education program (IEP) or a Social Security determination letter, may serve as verification of disability. Confidentiality policy iCanConnect is committed to ensuring that your privacy is protected. Information provided on this application form will only be used to determine eligibility for iCanConnect products and services. iCanConnect will not sell, distribute or lease your personal information to third parties unless you give permission, or if the iCanConnect program is required by law to do so. iCanConnect is committed to ensuring that personal information is secure. In order to prevent unauthorized access or disclosure, suitable physical, electronic and managerial procedures are in place to safeguard and secure the information iCanConnect collects. Applicant's Personal Data(Please fill in all fields)Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Other Address* Street Address Address Line 2 City State North DakotaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary PhonePhone Options Voice TTY VP Alternate PhonePhone Type Home Mobile Work Other Email State in which you are a permanent resident?*North DakotaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHave you participated in iCanConnect (the National Deaf-Blind Equipment Distribution Program) before?* Yes No What state/states did you participate in iCanConnect? (list all): Did you previously receive equipment through iCanConnect in another state? Yes No What state/states did you receive equipment through iCanConnect? (list all): How many people are living in your household?*Language preference (check all that apply): ASL Close Vision ASL/PSE Tactile ASL/PSE English (spoken) No Formal Language Pidgin Signed English Signed English Spanish (spoken) Other Which format do you prefer for written correspondence? Braille Email Large Print Standard Other Prefer to be contacted by:* Email Fax Text Message TTY (dial 711 for Relay) Video Phone Phone (voice) How did you hear about this program?iCanConnect.org websiteConference or SeminarDisability advocacy groupSpecialist in Deaf-Blind ServicesEducation provider /SchoolFamily MembersFriendsHealthcare providerInterpreterSenior CenterHelen Keller National CenterTechnology vendor(HKNC) representativeIndependent Living CenterNews / Media (television, magazine, radio)Social Media (Facebook, Twitter)State Deaf-Blind ProjectVocational Rehabilitation CounselorOtherFeedback / Suggestions (optional) Emergency Contact InformationAlternate Contact (in case of emergency) First Last Relationship with Applicant Spouse Child Caretaker Other Address Same as Applicant Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary PhonePhone Type Home Mobile Work Other Email Income Eligibility To confirm your income eligibility, please upload documentation that proves one of the following: You are currently enrolled in a federal program with an income eligibility requirement that does not exceed 400% of the Federal Poverty Guidelines, such as: Medicaid Supplemental Security Income (SSI) Federal public housing assistance or Section 8 Food Stamps or Supplemental Nutrition Assistance Program (SNAP) Veterans and Survivors Pension Benefit Proof of all household income (as described in Step 1)Please upload a copy of last year’s Federal IRS 1040 tax form(s) filed by you and members of your family/household or other evidence of your total family/household income, such as recent Social Security Administration retirement benefit statement(s) or other pension benefit statement(s). Documents may also be mailed, emailed, or faxed to: iCanConnect ND Assistive/NDBEDP 3240 15th St. S., Suite B Fargo, ND 58104 E-mail: firstname.lastname@example.org Fax: 701-365-6242 How will you be submitting your documentation? Upload Mail Email Fax Upload income eligibility documentation(If scanned documents are submitted, please use PDF format) Drop files here or Select files Max. file size: 300 MB. Applicant AttestationI certify that all information provided on this application, including information about my disability and income, is true, complete, and accurate to the best of my knowledge. I authorize program representatives to verify the information provided. I permit information about me to be shared with my state's current and successor program managers and representatives for the administration of the program and for the delivery of equipment and services to me. I also permit information about me to be reported to the Federal Communications Commission for the administration, operation, and oversight of the program. If I move and apply to any other state iCanConnect program, I also permit all state iCanConnect program(s) I participated in to send my program records to any other state iCanConnect program I apply to. If I am accepted into the program, I agree to use program services solely for the purposes intended. I understand that I may not sell, give, or lend to another person any equipment provided to me by the program. If I provide any false records or fail to comply with these or other requirements or conditions of the program, program officials may end services to me immediately. Also, if I violate these or other requirements or conditions of the program on purpose, program officials may take legal action against me. I certify that I have read, understand, and accept these conditions to participate in iCanConnect (the National Deaf-Blind Equipment Distribution Program).Enter name of applicant or parent/guardian (if applicant is under age 18):* SignatureSignature*Please type full name Date* MM slash DD slash YYYY If this application is completed by someone other than the applicant, please enter your nameBy entering my name above, I certify that I am signing this application for the applicant and with the applicant’s knowledge and consent. Privacy StatementThe Federal Communications Commission (FCC) collects personal information about individuals through the National Deaf-Blind Equipment Distribution Program (NDBEDP), a program also known as iCanConnect. The FCC will use this information to administer and manage the NDBEDP. Personal information is provided voluntarily by individuals who request equipment (NDBEDP applicants) and individuals who attest to the disability of NDBEDP applicants. This information is needed to determine whether an applicant is eligible to participate in the NDBEDP. In addition, personal information is provided voluntarily by individuals who file NDBEDP-related complaints with the FCC on behalf of themselves or others. When this information is not provided, it may be impossible to resolve the complaints. Finally, each state’s NDBEDP-certified equipment distribution program must submit to the FCC certain personal information that it obtained through its NDBEDP activities. This information is required to maintain each state’s certification to participate in this program. The FCC is authorized to collect the personal information that is requested through the NDBEDP under sections 1, 4, and 719 of the Communications Act of 1934, as amended; 47 U.S.C. 151, 154, and 620. The FCC may disclose the information collected through the NDBEDP as permitted under the Privacy Act and as described in the FCC’s Privacy Act System of Records Notice at 77 FR 2721 (Jan. 19, 2012), FCC/CGB-3, “National Deaf-Blind Equipment Distribution Program (NDBEDP),” https://www.fcc.gov/omd/privacyact/documents/records/FCC-CGB-3.pdf This statement is required by the Privacy Act of 1974, Public Law 93-579, 5 U.S.C. 552a(e)(3).CommentsThis field is for validation purposes and should be left unchanged.