Adaptive Technology Subsidy Application Form v1.2

Beyond Blindness

Adaptive Technology Subsidy Application Form

(Special Purpose Fund)

Accessibility notes and useful information:
-This online form uses edit boxes that requires the user to enter the data requested

-Help messages are available to assist user with data entry instructions

- * An asterix indicates that the field/task is mandatory, and a required action to enable the online form to be submitted, if these mandatory fields/tasks are not actioned the form will not proceed with submission to the organisation.

Personal Details

Members Name: (required entry in edit box) *

required entry in edit box

First name

Last name

Members Address: (required entry in edit box)

entry in edit box

Address line 1

Address line 2

City/Suburb

State/Territory

Postcode

Home Phone: Data format of entry in edit box must be (no area code) 4 digits space 4 digits

data format of entry in edit box must be 4 digits space 3 digits space 3 digits (no area code required)

Email address: (entry in edit box)

entry in edit box

Mobile: data format of entry in edit box must be 4 digits space 3 digits space 3 digits (no area code required) Asterix is required entry *

Required data format of entry in edit box must be 4 digits space 3 digits space 3 digits (no area code required)

I wish to apply for a subsidy for the following item of equipment: (required entry in edit box) *

entry in edit box of the equipment name

How does this equipment assist me?: required entry in edit box *

required entry in edit box for member to describe how the equipment will help

Supplier quote - required action: file in pdf/jpg format to upload: *

Required: Supplier quote to be attached to enable this online form to be submitted

Wait..

For the Member:

I have undertaken to research the best option for my current circumstances. It is my opinion, in conjunction with opinion of other professional sources as required, that this equipment is:

• appropriate to my current needs,
• will be of benefit in assisting me to gain or maintain independence,
• I have or will gain proficiency in its use and am able to access training if needed.

I agree: Required - Tick box to be selected if user agrees *

Required: Tick box to be selected if user agrees

I will be contributing the sum of :$ (entry in edit box - ex GST)

Entry in edit box

and wish to apply for a subsidy of : $ (entry in edit box - ex GST) *

Required: entry in edit box

Member Signature: (If user cannot sign, use tick box available below)

If user cannot sign, verbally signed tick box available below

Verbally Signed: (Select this tick box if you are verbally signing and unable to manually sign this form)

Select this tick box if you are verbally signing and unable to manually sign this form

Date: Required: Enter signature date *

Required: Enter signature date

Financial:

Select this tick box if supplier is to be paid subsidy funds directly from Beyond Blindness (*not to member)

Select this tick box if MEMBER is to be paid subsidy funds.

Bank Details - Member's bank account if requesting subsidy funds to be paid direct to member only

BSB Number (entry to edit box - digits only):

entry in edit box: digits only

Account Number (entry to edit box - digits only):

entry in edit box: digits only

Account Name: (entry in edit box)

entry in edit box

The Beyond Blindness (BB) Adaptive Technology equipment subsidies are intended to assist full members gain and maintain independence in daily living, study or employment.
As funds are limited it is anticipated that members will exhaust other specific government schemes where available i.e. employment schemes, NDIS and MAC before applying for funding through BB, in addition BB will only fund equipment when no other subsidies, co-payments or grants are a part of the total purchase. Criteria for applications are:

1. A subsidy of fifty (50) percent of the cost price may be paid on items $100.00 or more up to a maximum subsidy of $4000.00 over a 3-year period, commencing from first date of purchase.

2. A subsidy may be paid to assist with the cost of equipment or aids made exclusively for people with low vision or for multi-use mobile smart devices (e.g. “I” products) that come standard with adaptions for the blind. This does not include hardware such as computers/screens or laptops.

3. Any AT subsidy for any “Apple/Samsung” product application will be limited to the value of half of the cost of a basic version of the device applied for at the time with the maximum storage of 128GB.

4. The subsidy will only be approved to a member who is not currently receiving any form of Adaptive Technology/Equipment subsidy from any other organisations/programmes.

5. It is the responsibility of the member to provide supplier details and an official quote on a retail supplier’s letterhead. Bank Account details must be provided so that subsidy payments can be directed into the member’s account, (if not being paid directly to a supplier). Upon purchase a receipt MUST be provided via email or posted to the business support team as soon as the purchase is made.

6. For approved devices purchased on a plan, BB will subsidize half the cost of the device component of the plan only. It is the responsibility of the member to ensure they have the capacity to pay for any ongoing costs associated with internet or telephone carrier costs.

7. Replacement items will not be subsidized unless they are no longer fit for purpose or a change in eye condition renders them obsolete. For example, most smart devices should have a minimum life of three years before apps, batteries and software are no longer upgradable. Devices such as braille devices and CCTV’s should last for many more years. Applicants seeking to replace existing devices should discuss this with Beyond Blindness staff.

8. Subsidies will not be paid for equipment purchased prior to approval or for equipment not meeting BB guidelines

8. Applicants are encouraged to ensure devices are covered by their own insurance.

9. If a member finds the equipment unsuitable or unwanted and intends to sell it within two years of purchase, they should discuss this with BB staff as they may be required to refund the BB the subsidy.

Professional Recommendations and Training

To ensure equipment is suitable for achieving member goals accounting for eye-condition, aptitude and proficiency, all equipment subsidy applicants are encouraged to receive the professional endorsement of a low vision technology trainer or professional. In some cases, extra training sessions may be needed and will be the responsibility of the applicant. In the case of Smart devices such as mobile phones and tablets, proficiency is required in using the adaptive technology associated with the phone, not the ability of making a phone call.

NB. Beyond Blindness endeavors to assist with member applications in a prompt manner
however please note the wait time for processing may be approx. 7-10 working days.