SLIDE 16 Application Information
Person w n with d h disability – ty type e of dis disabilit bility; rela latio ionship ip to bo borrower
Borro rrower( r(s) pers rsonal data
AT Requ quested d and d how AT AT will ill be be us used
Verif ific icatio ion of Income sources, em employmen ent, t, SSI/SSDI DI, , SS, , pe pensio ion, child ild suppo pport, etc.
Finan anci cial al obligat ations – cr cred edit t car car de debt bt, car lo loans, mortga gage ge/rent, ju judgments, liens, bankruptcy info if if applic pplicable ble, etc.
Credit Report obtained
Bank account informa rmation
Total amount requested fo for the AT AT lo loan; total l cost of equ quipm ipment
Written price quote from ve vendor
ARIZONA LOANS for ASSISTI VE TECHNOLOGY
MariSol Federal Credit Union Loan Application
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All information on this application form is strictly confidential and will only be used to determine your need for and ability to repay this loan. Borrowers must demonstrate the ability to repay the loan Completion of this form does not guarantee that a loan will be granted. Please print or type; Nameofperson with a disability: --- -----
_ _ Describe the disability of the person who will be using the assistrve technology: __ Please check the box that best describes the relationship between the person with a disability and the borrower(s):0 SELF O SPOUSE/PARTNER O PARENT O CHILD 0 GUARDIAN D Other (specify) ___________ _ Explain how the assistive technology devices/equipment will affect independence. education, and/or employment (please be specific): _ _ ____ __ _ 4. Describe the type of assistive technology equipment or service to be purchased (use specific item brand names):. _ ___ _____ ___ __ _ 5. Total loan amount requested$
____
. You must attach an itemized price quote from each vendor regarding the device(s) you intend to purchase with this loan. Initials:
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ARIZONA
Technology Access Program
