Specialized Phone Program Application

Income Eligibility

If you do not meet the income requirements below DO NOT fill out this application. Please contact the ND Assistive offices at 1.800.895.4728 for other options that may be available to you.

Estimated Median Income for North Dakota Fiscal Year 2024

(effective 1/11/2024)
*Based upon Administration for Children and Families, Office of Community Services, Division of Energy Assistance.*
	Severe Hearing/ Speech/ Physical Impairment	Deaf
# of Persons in Household	Estimated Median Income	150% Estimated Median Income
1	$60,240	$90,360
2	$81,760	$122,640
3	$103,280	$154,920
4	$124,800	$187,200
5	$146,320	$219,480
For each additional person, add	$21,520	$32,280
Source: U.S. Department of Health and Human Services

Demographic Information

What is your Ethnicity?*

Hispanic or Latino

Not Hispanic or Latino

Unknown

What is your race?*

American Indian/ Native Alaskan

Asian

Black/ African American

Native Hawaiian/ Other Pacific Islander

Non-Minority (White, non-Hispanic)

White-Hispanic

Other

What is your Primary Language?*

English

Other

Do you live alone?*

Yes

No

Unknown

Do you feel socially isolated?*

Yes

No

Is your income at or below the national poverty level (see chart below)?*

Yes

No

2024 HHS Poverty Guidelines

(effective 1-11-2024)
Size of Family Unit	Poverty Guideline
1	$15,060
2	$20,440
3	$25,820
4	$31,200
5	$36,580
For each additional person, add	$5,380

Eligibility

I have a severe hearing, speech, vision, and/ or physical impairment that makes using a telephone difficult.*

Yes

No

I currently have or am in the process of getting phone service.*

Yes

No

I have family income at or under the guidelines given below.*

(Assistive reserves the right to request a copy of applicant’s federal tax return at a later date, if needed.)

Yes

No

Estimated Median Income for North Dakota Fiscal Year 2024

(effective 1/11/2024)
*Based upon Administration for Children and Families, Office of Community Services, Division of Energy Assistance.*
	Severe Hearing/ Speech/ Physical Impairment	Deaf
# of Persons in Household	Estimated Median Income	150% Estimated Median Income
1	$60,240	$90,360
2	$81,760	$122,640
3	$103,280	$154,920
4	$124,800	$187,200
5	$146,320	$219,480
For each additional person, add	$21,520	$32,280
Source: U.S. Department of Health and Human Services

Should we contact someone else regarding your application?

Yes

No

Professional Contact Person (Social Worker, Hearing Outreach, Vision Outreach, Case Manager, etc...)

If you are working with a professional (social worker, hearing outreach, vision outreach, case manager, etc...) please fill in the information below.

Professional Contact Name

First Last

Professional Contact Title

Professional Contact Phone

Professional Contact Email

Alternate Contact (Family, Friend, etc...)

If you would prefer we contact a family member or friend please fill in below.

Contact Name

First Last

Relationship with Applicant

Contact Phone

Contact Email

Acknowledgment

The preceding facts I have provided are true and complete to the best of my knowledge. (If under 18, applicant and parent/ guardian must sign.)

Applicant Signature

Applicant Signature*

Please type full name

Parent/ Guardian/ Power of Attorney Signature (if applicable)

Parent/ Guardian/ Power of Attorney Signature

Please type full name.

Condition of Acceptance of Telecommunications Device

Use and Care

I agree to protect this equipment against damage caused by dust, dirt, weather, and physical abuse.

Damage

If the equipment is damaged, I will not try to take it apart. I will return the equipment to Assistive.

Theft

If the equipment is stolen, I will report it to the police. A copy of the police report must be given to Assistive before I can get replacement equipment.

Loss

If I lose my equipment, I must report the loss to Assistive. I understand that I may not receive replacement equipment.

Travel

I understand that this equipment is the property of the State of North Dakota. I can travel out of North Dakota with my equipment for short trips and vacations. Any out-of-state travel with my equipment for more than 90 days requires written permission from Assistive.

Change of Address

If I move to another place in North Dakota, I have ten (10) days to report my new address to Assistive. If I plan to move to another state, I must return the equipment to Assistive. This must be done before I leave North Dakota. I understand that if I do not return this equipment, I may be charged with a misdemeanor or felony theft charge according to the ND Century Code 12, 1-23-07.

State Property

I understand that this equipment is property of the State of North Dakota and as such, I will not sell it. I will not give or loan it to others not in my immediate family. If I sell my equipment, I can be criminally prosecuted.

Liability

I agree to accept responsibility for said equipment and all claims, damages, and/or expenses caused by the use or misuse of said equipment by myself or anyone else.

Denial

If I do not keep these terms of conditions of acceptance, I can be denied the privilege of having telecommunications equipment provided by the State of North Dakota.

Death

In the event of my death, the executor or other responsible party must return the equipment to Assistive within thirty (30) days.

Repair

Assistive is responsible for all reasonable expenses to maintain and repair my equipment. If my equipment is damaged, lost, or destroyed because of negligence or abuse, I must pay for replacing or repairing the equipment.

Having read the above and conditions and having them explained to me I agree to comply with all of the conditions.

Applicant Signature

Applicant Signature*

Please type full name

Parent/ Guardian/ Power of Attorney Signature (if applicable)

Parent/ Guardian/ Power of Attorney Signature

Please type full name.

Questions?

Please call:
Toll-free: 1.800.895.4728
Local: 701.258.4728

You may also email TEDS at:
teds@ndassistive.org

This project is supported by funding granted through the North Dakota Department of Human Services, Aging Services Division.

Name

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

Income Eligibility

Estimated Median Income for North Dakota Fiscal Year 2024

Personal Information

Demographic Information

2024 HHS Poverty Guidelines

(effective 1-11-2024)

Physical Information

Equipment Questions