Colorado Communications Technology Program (CTP) Home ... · Stacy Gibson 729 South Tejon Street Colorado Springs, CO 80903 (719) 471-8181, ext. 177 e-mail: [email protected].

Colorado Communications Technology Program (CTP)

Home Communications Application

Proof of Annual Gross Income – provide the front page of your federal income tax return or a copy of your social security award letter, as an example. In order to qualify, the applicant's income must be less than 400% of the Federal poverty guidelines based on family size as indicated by the United States Department of Health and Human Services (page 8).

Applicant’s signature – sign Part I of the application.

Certifier’s signature – make sure the original signature of the certifier is in Part II.

Equipment selection – Visit a demonstration center (page 5) and make sure Part III is completed.

Please fill out this application and fax, scan and e-mail or mail it with the required supporting documents to:

JoAnne Hirsch, Communications Technology Program Manager Colorado Commission for the Deaf, Hard of Hearing, and DeafBlind 1575 Sherman St., Garden Level Denver, CO 80203 Voice: (303) 866-2097 VP: (720)949-7457 Fax: (303) 866-4831 E-mail: [email protected]

Page 1

This is an application for qualified citizens and residents of Colorado to receive communications technology. Please make sure all of this information is completed before you send your application. Send copies of your documents. Do not send originals. Proof of residency may be requested.

If you are eligible, you will receive a device that matches your telecommunication needs. Please note the program only provides the device and does not pay for service.

PART I: APPLICANT’S INFORMATION

Applicant’s name (First, Middle, Last) Address (Provide physical address of where you live, not P.O. Box.) City County: State: CO Zip:

Telephone number: Voice VP Other E-mail address: Date of Birth:

Gender: Male Female

I learned about CTP from:

Do you currently have: Amplified Phone Captioned Phone

Annual household income (count the number of people in your home and total everyone’s annual income):

1 person $ 3 persons $

2 persons $ 4 persons $

Income information will be used to determine if you are eligible to receive free communications technology. Eligible applicants shall be awarded program participation on a first-come, first- served non-discriminatory basis, in accordance with the approval date as determined by the dated signature of the CCDHHDB CTP staff. Applicants will be placed on a waiting list during times of fiscal constraint.

APPLICANT: I certify that all information given on this application is true. My parent/guardian or I accept responsibility for the equipment and its maintenance.

If applicant is under 18 years old, a parent/legal guardian must sign and assume full responsibility for the equipment.

Signature of Applicant Date

Parent/Legal Guardian (print)

Signature of Parent/Legal Guardian Date

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PART II: CERTIFICATION OF HEARING STATUS

CERTIFIER: Please identify and verify that the applicant will benefit from the use of communications technology. If you have any questions, contact us at: 303-866-2097 (V), 720-949-7457 (VP), 303-866-4831 (Fax), or [email protected].

Please note that the CCDHHDB CTP staff does not certify applicants for this program.

The applicant’s name (First, Middle, Last):

Check one: S/He is Deaf Deaf-Blind Hard of Hearing

Certifier Name License Number Name of Business Address City State Zip Phone Email

Check one: Licensed Physician Medical Professional Registered Audiologist or Hearing Aid Specialist Licensed Speech-Language Pathologist Service Professional (public or private agency that serves deaf, hard of hearing, deafblind)

I attest that I am eligible to certify under the provisions of the law. I am aware of the extent of the applicant’s hearing status and that the applicant can benefit from the requested equipment. For a captioned phone, I understand that this allows a person who is profoundly deaf or hard of hearing to read the conversation and that the calls go through a relay operator, individuals must be UNABLE to benefit from and use an amplified telephone and individuals must register the phone using their date of birth and last four digits of their social security number.

Signature of Certifier Date

This program is funded by the Colorado Commission for the Deaf, Hard of Hearing, and DeafBlind (CCDHHDB) through the Colorado General Assembly enactment of House Bill 2002-1180 that amended C.R.S. Chapter 216, Article 26.21.106. Monies that are collected as a surcharge on each residential phone line in the state of Colorado by the Public Utilities Commission are distributed from the Telephone Users with Disabilities Fund. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Please Type or Print (except for signatures) in blue or black ink.

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PART III: DEVICE SELECTION Visit a demonstration center near you (page five) to help better select a device(s) that makes your communications technology accessible. Consumer is limited to one phone (amplified or captioned). Consumer can select one signaler and personal listening device (with a phone or as a standalone order).

Amplified Telephones Corded

Clarity Alto Clarity Alto Plus (with Caller ID) Geemarc Ampli550 Clarity JV-35 (low vision) Amplicom PowerTel 780 (corded and cordless)

Amplified Telephone Cordless Panasonic KX-TGM450S Combo (with extra handset) Clarity XLC2 Clarity XLC3.4+ (with Caller ID) Clarity XLC3.4+ Combo (Caller ID plus extra Handset)

Bluetooth-Enabled Amplified Telephones (for households with Bluetooth-enabled cell phone service and/or home phone line)

Captioned Telephones CapTel 840 requires standard analog telephone line(s) (landline) CapTel 840i requires telephone service and high-speed Internet access CapTel 2400i requires telephone service and high-speed Internet access (touch screen) CapTel 880i for low vision requires telephone service and high-speed Internet access

Ring signalers

Sonic Alert SA201 (lamp light flasher) Sonic Blink BL300 (outlet light flasher) ClearSounds CR200 (loud ringer and light strobe) Serene CA-CX and BS-100 (light flasher and bed shaker for home phone and/or cell phone) Sonic Homeaware+Smartphone Notification (for mobile and home)

Personal Listening Devices Teltex HS-Smart Headset Artone 3Max Bluetooth Neckloop (wireless streamer for T-Coil hearing aids)

Answering Machine Amplicom AB900

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Panasonic KX-TGM430B (with extra handset) Clarity BT914 (cordless)

Clarity XLC7BT (cordless)

Demonstration Centers (please call ahead before visiting):

Assistive Technology Partners Julia Beems 1201 5th Street, Suite 240Denver, CO 80204 (303) 315-1284e-mail: [email protected] (to make an appointment)

The Independence Center Stacy Gibson 729 South Tejon Street Colorado Springs, CO 80903 (719) 471-8181, ext. 177e-mail: [email protected]

Connections for Independent Living Sarah Burnett 1331 8th AvenueGreeley, CO 80631 (970) 352-8682e-mail: [email protected]

Disabled Resource Services Jenny Miller 1017 Robertson Street, Unit B Fort Collins, CO 80524 (970) 482-2700e-mail: [email protected]

Center for Independence Denice Roberts 740 Gunnison Ave. Grand Junction, CO 81501 (970) 241-0315, ext. 29e-mail: [email protected]

Center Towards Self Alliance Judith Ferguson 901 West 8th Street Pueblo, CO 81003 (719) 546-1271e-mail: [email protected]

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Clarity Sempre

AMPLIFIED PHONES (all are for moderate to severe hearing loss) LOW VISION PANASONIC KX-TGM450S With Digital Answering Machine

• Amplifies up to 50dB• Slows speech in real time

andmessages

• Background noise reduction• Speakerphone

AMPLICOM POWERTEL Amplified Corded Phone with Integrated Answering Machine and Included Expandable Cordless Handset

• Amplifies up to 50dB• Talking caller ID/phonebook• Speakerphone• Tone control• Digital answering

machine

CLARITY ALTO & ALTO PLUS

Digital Extra Loud Big Button Speakerphone

• Amplifies up to 53dB• Built-in large

speakerphone• Talking Caller ID

GEEMARC AMPLI550 Extra loud, big button corded phone

• Amplifies up to 50dB• Caller ID and large LCD• Speakerphone• Volume and tone control

CLARITY XLC2, XLC3.4+ COMBO

Extra loud, big button cordless

• Amplifies up to 50dB• Extra loud

speakerphone• Talking Caller ID• Extra loud ringer• Tone Control• Caller ID Display (XLC3.4 and Combo)

BLUETOOTH: PANASONIC KX-TGM430B CLARITY BT914CLARITY XLC7BT

• Panasonic cordless amplifies up to 50dB• Clarity BT914 cordless amplifies up to 40dB

AMPLIFIED PHONES

CLARITY JV35 Jumbo Talking Keys with Voice-Activated Answering

• Amplifies up to 50dB• Jumbo keys with Braille lettering• Talk-back keys• Three programmable one-touch

emergency buttons and 10 memorybuttons

• Voice and tone control

TTYs TTYs are available upon request.

To ensure you select the correct equipment, visit a demonstration center

(page 5) or contact Teltex at 888-515-8120 or go to www.teltex.com for

amplified phones or WCI at 800-233-9130 or go to www.weitbrecht.com for

CapTel phones.

• Clarity XLC7BT cordless amplifies up to 50dB

CAPTIONED PHONES

Allows a person who is profoundly deaf or hard of hearing to read the conversation.

• Calls go through a relay operator• Individuals must be UNABLE to benefit

from and use an amplified telephone.• Must register the phone using their date of

birth and last four digits of their socialsecurity number

CAPTEL 840

• Requires standard analogtelephone line (landline)

• Calls initiated will be captioned• When receiving a call, your caller

must dial a toll-free number first andthen enter your number

CAPTEL 840i • Requires phone service AND

high-speed internet• All calls made and received will be

captioned

CAPTEL 880i, LOW VISION

• Requires phone service ANDhigh-speed internet

• 10-inch caption window

CAPTEL 2400i

• Touchscreen• Requires phone service

AND high-speed internet• Speakerphone

RING SIGNALER ACCESSORIES

LIGHT SIGNALERS

SONIC ALERT SA201 Alerts you that the phone is ringing by flashing any lamp that is plugged into its Plug-outlet.

SONIC BLINK BL300 This built-in high intensity strobe light projects 360° when flashing to eliminate blind spots. It’s perfect for places where a lamp is normally not used.

Included Sonic Ring Elite TR75VR (transmitter).

SERENE CA-CX AND BS-100

For home phone and/or wireless device. Includes bed shaker.

SOUND SIGNALER

CLEARSOUNDS CS-CR200 LOUD RINGER

This Loud Ringer and Flasher alerts you that your phone is ringing with a super loud adjustable volume.

Home and Mobile

Homeaware

HomeAware™ Smartphone -Wireline and Mobile phone signaler with bed shakerHomeAware™ Smartphone -Wireline and Mobile phone signaler with bed shakerThe HomeAware Smartphone signaler will alert you via its extra loud 110 dB audible alert, flashing strobe and bed shaker.

AMPLIFIED ACCESSORIES TELTEX HS-SMART HEADSET • Two Ear Piece Headphone• Microphone included

Artone 3Max Bluetooth Neckloop • Wireless streamer for hearing aid

and implant users during mobilephone use

• Requires T-Coil in hearing aid

ANSWERING MACHINE AMPLICOM AB900

• Amplifies up to 40dB• Tone Control• Speed Control (slows

speech)

Low Income Guidelines for Colorado Residents

To qualify and receive telecommunication equipment, the applicant's income must be less than 400% of the

Federal Poverty Level (FPL) Guidelines based on family size as indicated by the United States Department of Health and

Human Services.

Below is the 400% FPL for Colorado:

Persons in Family

Colorado

1

2

3

$51,040

$68,960

$86,880

4

5

6

$104,800

$122,720

$140,640

7

8

$158,560

$176,480

Families with more than 8 persons, add: $17,920 *