Technology Assistance Program Application
Application Date:
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RadDatePicker
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Calendar
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Application Date is required.
Veteran Status:
None selected
Veteran
Surviving Spouse/Child of a Veteran
Not a Veteran
National Guard Member
Veteran Status is required.
Region:
None selected
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Map of Regions
Region is required.
Last Name:
Last Name is required.
Last Name can only contain letters and space.
First Name:
First Name is required.
First Name can only contain letters and space.
Middle Initial:
Middle Initial can only contain letters and space.
Date of Birth:
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
<<
<
November 2024
>
<<
November 2024
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T
W
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F
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44
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Birthday is required.
Qualify Disability:
None selected
Person with difficulty Speaking
Hard of Hearing
DeafBlind
Deaf
Qualify Disability is required.
Pay Coupon Application (Income Information not Required)
Family Size:
"Family" means the applicant, his dependents and any person legally required to support the applicant, including a spouse
Family Size is required.
Please enter a valid family size.
Family Gross Income:
Please select Monthly or Annual.
Monthly
Annual
Family Income is required.
"Gross Income" means the income , total cash receipts before taxes from all sources of the applicant, his dependents, and any person legally required to support the applicant, including a spouse
Documentation Required - VDDHH will contact you to request required documentation
Home Address:
Home Address is required.
Invalid characters in Home Address.
City:
City is required.
Invalid characters in City.
State:
Zip:
Zip is required.
Please enter a valid 5-digit or 5-digit hyphen 4-digit zip code.
Email Address:
Email is required.
Please, enter a valid email address.
Primary Phone Type/Number:
Please select a primary phone type.
VP
Voice
TTY
Primary Phone# is required.
Secondary Phone Type/Number:
VP
Voice
TTY
Other Contact Name:
Other Contact Phone #:
APPLICANT ACKNOWLEDGEMENT AND SIGNATURE
I understand and agree that:
All information provided above is accurate.
Providing false information may result in denial of my TAP application, and any equipment issued must be returned.
If I move before I receive my equipment, I will inform VDDHH of my new address.
My personal information may be shared with D/HH Specialists for equipment delivery.
VDDHH is not responsible for my telephone or internet bill.
I accept responsibility for the equipment, including repairs and maintenance costs.
If I do not qualify for equipment at no cost, I have the option of paying the state contracted cost for equipment.
I will need to submit documentation/proof of my Virginia Residency, Family Size income, or Veteran status when requested by the TAP Administration.
Please check the box to agree the terms
By checking this box, I agree to the above terms
Signature:
Signature is required.
Signature can only contain letters and space.
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