8. Commonwealth of Pennsylvaniaâs
Telecommunication Device Distribution Program
APPLICATION FORM
It could be the answer to your telecommunication needs!
The Telecommunication Device Distribution Program (TDDP) established by Act 34-
1995 and amended by Act 181-2002 provides telecommunication devices to
qualified applicants. These devices enable eligible individuals with disabilities to
access telephone services independently. To be eligible, individuals must complete
this application and meet all criteria listed below.
TDDP is implemented by Pennsylvaniaâs Initiative on Assistive Technology (PIAT), a
program of the Institute on Disabilities at Temple University, in conjunction with the
PA Office of Vocational Rehabilitation (OVR) and the PA Public Utility Commission
(PUC).
CRITERIA
ďˇ Person with a Disability
A person with a disability or disabilities that prevents him/her from making or receiving telephone calls
independently. A licensed physician, audiologist, speech pathologist or a representative of a qualified
State agency (e.g. Office of Vocational Rehabilitation Counselor, Department of Public Welfare or
Social Security Administration Case Worker) must certify the disability.
ďˇ Income Limits
Applicantâs gross income of 200% (not including family/household income) of federal poverty level or
less. (see financial eligibility criteria)
ďˇ Age
Six (6) years or older.
ďˇ Residence
A resident of Pennsylvania.
ďˇ Resources
Must have access to residential telephone service and possess the ability to learn how to use a
telecommunication device.
ďˇ Information will be kept confidential
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9. Except as required by law.
ďˇ Equipment Ownership and Responsibility
Equipment will be delivered to your home. It then becomes YOUR PROPERTY and YOUR
responsibility.
NOTE: There is a Limited Manufacturer Defect Warranty on all equipment purchased under this
program. If your equipment is defective or if it should fail, it will be your responsibility to contact
the Manufacturer for warranty repair. Repairs for damages due to abuse or neglect are not covered
under any warranty and are YOUR RESPONSIBILITY. Stolen equipment can only be replaced upon
receipt of a copy of the police report of the theft.
ďˇ Make a copy of your application for your records.
ďˇ Return the completed ORIGINAL application (see mailing address on front page).
FINANCIAL ELIGIBILITY CRITERIA / 2009-10 GUIDELINES
Size of family unit Gross Income (200% of federal poverty level)
1 ____________________________________________ $21,660
2 ____________________________________________ $29,140
3 ____________________________________________ $36,620
4 ____________________________________________ $44,100
5 ____________________________________________ $51,580
6 ____________________________________________ $59,060
7 ____________________________________________ $66,540
8 ____________________________________________ $74,020
If you need help in completing this application, or need it in an alternate format,
please contact us.
Phone: 800-204-7428 voice / 866-268-0579 TTY
Fax: 215-204-9371 / Email: tddp@temple.edu
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10. TDDP Application /TDDP Eligibility
Your eligibility will be determined when you have submitted a completed application and all
documentation. To avoid delay, please type or print clearly and make sure all sections of the
application have been completed. If questions do not pertain to you, write âN/Aâ on the line provided.
SECTION 1 APPLICANT EQUIPMENT NEED
1) Do you already own telecommunication equipment similar to what you are applying for?
ď˛ YES
ď˛ NO
If YES, please check the correct answer below:
My equipment
o is broken or only works sometimes
o is borrowed
o does not meet my needs
Important NOTE: If you have working equipment that meets your needs you will not be eligible for
the program at this time.
SECTION 2 CERTIFICATION
Please note: This section must be completed by a licensed physician, audiologist, or speech-
language pathologist acting within the scope of his/her license, OR representative of a qualified
agency, such as an Office of Vocational Rehabilitation (OVR) Counselor, Department of Public
Welfare (DPW) or Social Security Administration Case Worker. Make sure all lines are completed
and appropriate spaces are marked before submitting this application.
1) Applicant being certified
Last name ____________________ First name _______________________ Middle initial _____
2) Check the type of disability being certified.
o cognitive o low vision/blind
o deaf o physical
o deaf blind o speech
o hard of hearing
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11. I am a:
o licensed audiologist
o licensed speech pathologist
o licensed physician
o representative of a qualified state agency
3) Certifying professional
Name ___________________________________ Title _________________________________
Agency_______________________________________________________________________
PA Professional License Number (if applicable) _______________________________________
Area code ____ Phone __________________________ Fax ____________________________
I certify that the applicant named above has the disability indicated, and that s/he requires
technology to independently access telecommunications services.
Signature of professional ___________________________________ Date ________________
SECTION 3 TDDP APPLICANT INFORMATION
1) Person applying for equipment
Last name ____________________ First name _______________________ Middle initial _____
Date of birth (month/day/year) _____________________________________________________
Street address _________________________________________________________________
(Note: Equipment cannot be delivered to a PO Box; you must provide a street address)
City _________________________ State __________________________ Zip ____________
County (e.g. Allegheny, Snyder) ___________________________________________________
Person assisting applicant with this application, if any.
Name ___________________________________ Phone _______________________________
2) Name of parent or guardian (for applicant under age18)
3) Telephone number: home ( ) - other ( ) -
4) Annual income:
Applicantâs gross income only, including Social Security and/or pension income if applicable. Do
not include family/household income. If applicant has no income, please write NONE.
$____________________
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12. 5) Total number of members in family unit (including applicant):
Applicant ( 1 ) + number of other family members (- ___ ) = total members in family unit ( ____ )
6) My primary reason for using the TDDP is (check one):
o Cannot afford equipment
o Equipment available to me only through TDDP
o I could get the device paid for through other programs, but the system is too complex and
the wait is too long
7) These questions are optional (for reporting purposes only).
Race:
o Caucasian
o African-American
o Asian
o Latino
o Other (specify)_________
Gender:
o male
o female
8) Please tell us how you heard about the TDDP: ______________________________________
9) Applicantâs statement and signature
(Note: This application should be submitted no later than 30 days after you have signed and dated it.)
I certify that all information provided on this application is true, complete and correct. I understand
that if I purposely provide false information I may be subjected to legal action. Program officials
have my permission to verify the information provided. I certify that I have read, understand and
accept all conditions set forth in this application and have the ability to learn to use the equipment
I selected.
Applicant signature ____________________________________________ Date____________
Parent or legal guardian signature________________________________ Date____________
(if applicant is a minor, or has a legal guardian)
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13. DOCUMENTATION REQUIRED FOR TDDP APPLICATION
Do you have all the documentation requested? To complete the TDDP
application, you must submit photocopies (since originals cannot be returned) of
the documentation listed below.
ďˇ 1. Proof of Applicantâs (including minors) Residence in Pennsylvania
Submit ONE of the following: copy of current driverâs license, non-driver I.D., utility bill, dated Social
Security correspondence, copies of W-2âs, school report card, or other documentation pre-printed
with the applicantâs name and address.
ďˇ 2. Proof of Applicantâs Income
Submit a copy of each item that applies to you.
Income statements including W-2âs, 1099s or award letters for retirement and/or Social Security
income. If you do not have a copy of your Social Security income statement you can call 1-800-772-
1213 and request a âBenefits Verification Letterâ. Bank statements and pay stubs cannot be
accepted. If applicant has no income write âNONEâ. Note: If the applicant is a minor child, income
requirements are based on the childâs income only, not family or household income.
ďˇ 3. Proof of Telephone Service
Submit a copy of ONE page of your most recent telephone bill with your telephone number appearing
on it. If phone service is shared in a residential facility, submit a statement on facility letterhead
signed by Administrator or Social Worker and include applicantâs name and phone number.
ďˇ 4. Certification of Disability
Have Section 2 of this application completed by one of the following licensed professionals:
physician, audiologist, speech pathologist, or representative of a qualified state agency (e.g. Office of
Vocational Rehabilitation Counselor, Department of Public Welfare or Social Security Administration
Case Worker). To avoid delays make sure the entire section is completed before submitting the
application.
IMPORTANT: If you are unsure of the type of equipment that will meet your needs, the TDDP
encourages you to contact PAâs Assistive Technology Lending Library. The Lending Library
(ATLL) allows you to borrow equipment (at no cost) to help you decide what will work for you.
Also, equipment demonstrations can be arranged through one of the regional Assistive
Technology Resource Centers (ATRCs) of Pennsylvaniaâs Initiative on Assistive Technology.
Please contact the TDDP for more information on the Lending Library, ATRCs, and other
resources. If none of the listed equipment will meet your needs, please contact the TDDP:
Phone: 800-204-7428 voice / 866-268-0579 TTY / Email: tddp@temple.edu
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14. EQUIPMENT SELECTION
CATEGORY A:
Select only ONE device below that best fits your needs.
ďą Amplified Phone Clarity XL50
ďą Amplified Phone Serene Innovations HD-60J
ďą Amplified Phone (cordless) Clarity C4205
ďą Amplified Phone (cordless) Clarity C4220
ďą Amplified Phone (cordless) Clarity C4230
ďą Amplified Talking Phone Ameriphone Dialogue JV35
ďą In-line Handset Amplifier Ameriphone
ďą Amplified Photo Phone Serene Innovations HD-30P
ďą Amplified Photo Phone Serene Innovations HD-40P
ďą Captioned Phone CapTel
ďą Captioned Phone CapTel USB (computer not included)
ďą Photo Phone Doro MemoryPlus 319ph
ďą Big Button Speakerphone Reizen
ďą Voice Activated Dialer AblePhone 5000
ďą Headset Phone Plantronics CT-14
ďą Hands Free Speakerphone optional accessories:
o lapel mic
o headset mic
o air switch
o pillow switch
RC200
ďą Voice Carryover Phone Ameriphone Dialogue VCO
ďą TTY Superprint 4425
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15. ďą TTY with Large Visual Display Superprint Pro80
o Blue-Green LVD
o Rose-Red LVD
o Amber LVD
Superprint Pro80
o ď TTY Hearing Carryover with speakers Ameriphone Q90D
o TTY Voice Carryover Phone Uniphone 1140
o ď Talking Keyboard DynaWrite with PhoneIT
o ď Telephone Fluency System Casa Futura
o ď Deaf/Blind Communicator with Braille and TTY Humanware
CATEGORY B:
Select only ONE signaler below.
ď˛ Loud Ring Signaler CrystalTone
ď˛ Flashing Light Signaler Sonic Alert
ď˛ Vibrating Signaler OmniPage Kit (receiver shown)
ď˛ Lamp Flasher and Bed Shaker Clarity (only for use with Clarity XL50 and Clarity
C4230
ď˛ NONE (No signaling device from Category B is needed.)
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16. Checklist
After you have finished the TDDP application, read and check the boxes below to ensure you have
completed all components:
ď˛ Answered all of the Applicant Information
ď˛ Had the Certification signed by a qualified individual
ď˛ Signed the Applicantâs Statement
ď˛ Selected equipment that is right for you (Your equipment selection is FINAL)
ď˛ ATTACH A COPY OF PROOF FOR EACH OF THE FOLLOWING:
__Proof that you live in Pennsylvania
__Proof of income
__Proof of home telephone service
ďˇ Make a copy of your application for your records.
ďˇ Return the completed ORIGINAL application (pages 3 through 6), along with
COPIES of required documentation to:
Telecommunication Device Distribution Program
Institute on Disabilities at
Temple University/ PIAT
Lisa Troy, TDDP Program Coordinator
1601 North Broad Street
USB Suite 610
Philadelphia, PA 19122-6024
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17. PIAT PROGRAMS
At work, At home, In the community
Device Demonstrations
AT (Assistive Technology) demonstrations are hands-on
opportunities to learn more about different AT devices so individuals
and families can make an informed choice about what will work best
for them. Demonstrations are individually scheduled upon request.
Device Loans
Pennsylvanians of any age and ability can borrow AT devices, at no
cost, to try at work, school, home or in their neighborhoods. This
short-term loan program allows individuals with disabilities to âtry
before they buy,â and helps them and their families make the right
choice before a device is purchased.
Recycled and Exchanged Equipment Partnership
Previously-owned devices are an affordable option instead of
buying new, and several options are available to Pennsylvanians.
These include a classified listing of used devices, an online auction
site and recycling programs that clean and repair devices for reuse.
Public Awareness Activities
Information and referral provides assistance via phone, e-mail or
U.S. Mail, about the availability of AT devices and services; AT
exhibits and presentations offer information at conferences, group
meetings, staff in-services, and other events; and individualized
assistance helps consumers navigate the maze of funding options
available to obtain needed AT.
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18. Telecommunication Device Distribution Program
PIAT administers Pennsylvaniaâs Telecommunication Device
Distribution Program, through which eligible Pennsylvanians with
disabilities can obtain free telephone equipment to help improve
their ability to access the phone.
AT Training and Technical Assistance
AT training opportunities educate health care providers, educators,
employers, agency staff, as well as individuals with disabilities and
their families, increasing their AT-related knowledge and skills.
Technical assistance provides collaborative problem-solving with
public and private agencies to develop and improve policies related
to AT.
Information and Referral
800-204-7428 (voice)
866-268-0579 (TTY)
ATinfo@temple.edu
http://disabilities.temple.edu/programs/assistive/piat
COLLABORATORS
Pennsylvania Assistive Technology Foundation
www.patf.us
888-744-1938 (voice/TTY)
Disability Rights Network of Pennsylvania
www.drnpa.org 800-692-7443 (voice)
877-375-7139 (TTY)
Institute on Disabilities at Temple University, College of Education
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19. PIAT Assistive Technology Resource Centers
Pennsylvaniaâs Initiative on Assistive Technology
(PIAT)
Counties Served: Bucks, Chester, Delaware,
Montgomery, Philadelphia
Contact: Sandi McNally
Institute on Disabilities at Temple University
1601 N. Broad St., Suite 610, Philadelphia, PA 19122
(800) 204-PIAT (7428) or (215) 204-5967 Voice
(866) 268-0579 TTY; (215) 204-9371 Fax
E-mail: ATinfo@temple.edu, www.disabilities.temple.edu
Community Resources for Independence Counties
Served: Clarion Crawford, Erie, Forest, Mercer, Venango,
Warren
Contact: Gregory Staub
3410 West 12th Street, Erie, PA 16506
(800) 530-5541 or (814) 838-7222 Voice
(814) 838-8115 TTY; (814) 838-8491 Fax
E-mail: piat@crinet.org, www.crinet.org
Three Rivers Center for Independent Living
Counties Served: Allegheny, Armstrong, Beaver, Butler,
Indiana, Lawrence, Westmoreland
Contact: Kevin Huwe
900 Rebecca Avenue, Pittsburgh, PA
15221-2997
(800) 633-4588 Voice; (412) 371-7700 ext. 111 Voice
(412) 371-6230 (TTY); (412) 371-9430 Fax
E-mail: khuwe@trcil.org, www.trcil.org
Update 9/09 - aed
20. Life and Independence for Today
Counties Served: Cameron, Clearfield, Elk, Jefferson,
McKean, Potter
Contact: staff
503 Arch Street Extension
Saint Marys, PA 15857-1779
(800) 341-5438 Voice or (814) 781-3050 Voice
(814) 781-1917 Fax/TTY
E-mail: liftinr@liftcil.org, www.liftcil.org
United Cerebral Palsy of Central PA
Counties Served: Adams, Cumberland, Dauphin,
Franklin, Fulton, Huntingdon, Juniata, Lebanon, Mifflin,
Perry, Snyder, York
Contact: Jackie Wardle
925 Linda Lane, Camp Hill, PA 17011
1-800-998-4827 or (717) 737-3477 Voice/TTY
(717) 737-9017 Fax
E-mail: jwardle@ucpcentralpa.org, www.ucpcentralpa.org
Roads to Freedom
Counties Served: Centre, Clinton, Columbia, Lycoming,
Montour, Northumberland, Sullivan, Tioga, Union
Contact: Ray Pysher
210 Market Street, Williamsport, PA 17701
(800) 984-7492 or (570) 327-9070 Voice
(866) 842-5426 TTY, (570) 327-8610 Fax
E-mail: rpysher@cilncp.org, www.cilncp.org
Update 9/09 - aed
21. United Cerebral Palsy of N. Eastern PA
Counties Served: Bradford, Lackawanna, Pike,
Susquehanna, Wayne, Wyoming
Contact: Linda Mesavage
425 Wyoming Avenue, Scranton, PA 18503
(877) 827-8324 NE PA Only, (570) 347-3357 Voice
(570) 347-3117 TTY; (570) 341-5308 Fax
E-mail: ucptech@yahoo.com, www.ucpnepa.com
Tri-County Patriots for Independent Living
Counties Served: Bedford, Blair, Cambria, Fayette,
Greene, Somerset, Washington
Contact: Donya Smith
69 East Beau Street, Washington, PA 15301
(724) 223-5115 Voice, (724) 228-4028 (TTY)
(724) 223-5119 Fax
E-mail: donya@tripil.com, www.tripil.com
Good Shepherd Rehab Hospital
Counties Served: Berks, Carbon, Lancaster, Lehigh,
Luzerne, Monroe, Northampton, Schuylkill
Contact: Carrie Kane
850 South 5th Street Allentown PA 18103
877-629-1717 or (610) 778-1015 Voice
(610) 776-8375 Fax
E-mail: ckane@gsrh.org, www.goodshepherdrehab.org
Update 9/09 - aed
22. The Pennsylvania Assistive Technology Foundation (PATF) is a
non-profit organization that provides low-interest loans for the
purchase of assistive technology devices and services. Examples
of items that may be eligible for funding include: adapted
vehicles, home modifications, hearing and low-vision aids,
elevators, stair glides and lifts, computers with specialized
software and/or hardware, and seat lift chairs. Successful
participation in this program may also improve your credit rating.
PATF services:
1. Pennsylvania residents who have a disability and older
Pennsylvanians who need assistive technology.
2. People of all income levels. Applicants must have the ability
to repay a loan.
Additional PATF facts:
1. The current interest rate for low-interest loans larger than
$1,000 is 4.5%. The repayment period is based on the
useful life of the device.
2. The interest rate for loans that range between $100 and
$1,000 is 0%. The minimum monthly payment is $20.
3. If the borrower (consumer) is low-income â meaning has a
household income of less than 200% of the federal poverty
guidelines â a partial grant may be available if the applicant
is interested in borrowing less than $1,000. For a family of
one, the maximum income to be eligible for a partial grant is
$15,600. For a family of two, the maximum income is
$21,000.
For more information about PATF, please call 888-744-1938 or e-
mail: patf@patf.us. The web address is: www.patf.us.
23. Pennsylvaniaâs
Assistive Technology Lending Library
Institute on Disabilities at Temple University
College of Education
What is assistive technology?
An assistive technology device is any device used by a person with a
disability in order to communicate, work, play, learn, do chores at home, or
get around in the community. Assistive technology devices can increase
the ability of individuals with disabilities and older adults to be independent,
contributing, and included members of their communities.
Assistive technology services help people with disabilities identify, obtain,
and use assistive technology devices.
What is Pennsylvaniaâs Assistive Technology Lending
Library?
Pennsylvaniaâs Assistive Technology Lending Library is a free service
which enables Pennsylvanians with disabilities of all ages to try a variety of
assistive technology devices, in order to decide what device is best suited
to their needs. Pennsylvaniaâs Assistive Technology Lending Library is
supported by state dollars with additional funding from Pennsylvaniaâs
Initiative on Assistive Technology (PIAT), vendors and contributions from
users.
The inventory of Pennsylvaniaâs Assistive Technology Lending Library
consists of assistive technology devices which can be easily shipped, do
not require installation or permanent modifications and do not involve
weight bearing. There are local branches of Pennsylvaniaâs Assistive
Technology Lending Library across the Commonwealth, as well as
regional Assistive Technology Resource Centers (ATRCs) that can help
you learn more about the devices and how to borrow them. If you donât
know what you need, would like to see devices demonstrated, need help in
learning to use the device, or if you successfully try a device and need help
in acquiring it for your own use, the ATRC staff can help.
Pennsylvaniaâs Assistive Technology Lending Library is a free program
available to all Pennsylvanians with disabilities, regardless of age or
disability, who would like to try out assistive technology devices prior to
purchasing them.
24. What devices are available through Pennsylvaniaâs
Assistive Technology Lending Library?
There is a wide selection of devices for you to borrow, including devices
that can help you: Communicate with others
ďˇ Control your environment
ďˇ Hear what others are saying
ďˇ Do everyday activities
ďˇ Access computers
ďˇ Read printed materials
If the device you want to try is not available in the inventory, the ATRC
may be able to help you find other ways to borrow or try the device.
How does Pennsylvaniaâs Assistive Technology Lending
Library work?
Requests to borrow equipment may be made by you, your family member,
friend or advocate, or someone who is presently helping you with your
assistive technology needs (e.g. therapist, teacher, rehabilitation
counselor). For devices that are complicated, you may be asked to identify
someone who is familiar with the device who will help you use it during a
loan period. Employers, schools and university faculty may also borrow.
Return your completed application to the ATRC serving your region for
processing.
After your application is received by the ATRC, you will be informed of an
actual or approximate shipping date. Your device will be delivered to you,
and is yours to use for the specified loan period. When the loan period is
over, the device will be picked up and returned to the Lending Library.
There is no cost to you for pick up or delivery of the device. Anyone
interested in borrowing a device can get an application and view the
equipment catalog online or an application can be requested by calling toll-
free:
877-PA AT LEND (877-722-8536) voice/TTY
800-204-PIAT (800-204-7428) voice
866-268-0579 TTY
25. For more information
For more information about Pennsylvaniaâs Assistive Technology Lending
Library or for the Assistive Technology Resource Center nearest you
email: atlend@temple.edu or go to the website at
http://disabilities.temple.edu/atlend
Institute on Disabilities
at Temple University
1601 North Broad Street
610 University Services Building
Philadelphia, PA 19122
800-204-7428 voice
866-268-0579 TTY
Fax 215-204-9371
http://disabilities.temple.edu/atlend
atlend@temple.edu
The Institute on Disabilities is Pennsylvaniaâs University Center for
Excellence in Developmental Disabilities, Education, Research, and
Service at Temple University. Pennsylvaniaâs Initiative on Assistive
Technology (PIAT) is a program of the Institute on Disabilities. PIAT is
funded by a grant from the U.S. Department of Education under the
Assistive Technology Act of 1998, as amended.
This brochure is available in alternate formats, upon request.
