Fillable State of New Jersey Department of Human Services (State of New Jersey)

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State of New Jersey Department of Human Services (State of New Jersey)

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July 2021 Page 1
State of New Jersey
Department of Human Services
Division of the Deaf and Hard of Hearing
Equipment Distribution Program
Application
The New Jersey Division of the Deaf and Hard of Hearing provides free assistive devices to those who are deaf
or hard of hearing and who meet income eligibility requirements. To combined household income must be
400% of the federal poverty level. Please input the number of members of your household here.
The 2021 income guidelines are listed
2021 Federal Poverty Guidelines
Number of persons in famil
y/household 400%
1
$51,520
2
$69,680
3
$87,840
4
$106,000
5
$124,160
For each additional person, add $18,160
Please follow this checklist to complete this application.
· A copy of NJ government issued ID, such as a driver’s license or identification card
· A copy of your NJ telephone bill and/or internet service showing your name, address, and telephone number
· A copy of your most recent pay stubs or source of income, i.e. SSI, SSDI OR a copy of your most recent
Federal Income Tax Form 1040 and/or NJ Income Tax Form 1040
· Completed Application (please print legibly or complete form online and then print for signatures)
· Completed Certification of Disability (please print legibly or complete form online and then print for
signatures)
· Check the equipment requested
· Mail, email, or fax all pages of this form to: DDHH Equipment Distribution Program
PO Box 074
Trenton, NJ 08625-0074
Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
New Jersey Equipment Distribution Program Form
Application Form
Please type or print clearly in blue or black ink.
First Name: ____________________ Middle Initial: __ Last Name: _____________________________
Mailing Address
Street – line 1: ________________________________________________________________________
Street – line 2: ________________________________________________________________________
City: _____________________________ County: ______________ Zip Code: ______________________
Telephone Number: ___________________ (check one) □ Voice □ VP □ Fax □ TTY/TDD □Cell
Email:
Physical Address (If not the same as mailing address)
Street – line 1: ________________________________________________________________________
Street – line 2: ________________________________________________________________________
City: _________________________________ County: ______________ Zip Code: __________________
Proof of Identity
Please provide a copy of each as described below:
• A copy of your NJ Photo Driver’s License or your N J Photo State ID
• A copy of your NJ telephone bill and/or internet service showing your name, address, and telephone #
• A copy of your most recent pay stubs or source of income i.e. SSI, SSDI OR a copy of your most recent
Federal Income Tax Form 1040 and/or NJ Income Tax Form 1040
How do you identify your disability: (Please check one)
Deaf/Hard of Hearing: Mild __ Moderate __ Profound __ Unable to speak intelligibly __
All statements I have made in this application are true and correct to the best of my knowledge.
Applicant’s Signature: ____________________________________ Date: _________________________
DDHH Equipment Distribution Program
PO Box 074, Trenton, NJ 08625-0074
Phone: 609-588-2648 or 800-792-8339, Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
July 20 21 Page: 2
DDHH Equipment Distribution Program
PO Box 074, Trenton, NJ 08625-0074
Phone: 609-588-2648 or 800-792-8339, Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
July 2021 Page: 3
New Jersey Equipment Distribution Program Form
Certification of Disability
Certifier: Please identify and verify that the applicant will benefit from the use of the requested
technology. Please type or print clearly in blue or black ink.
Applicant’s Name: _________________________________________________________
Today’s date: (mm/dd/yyyy): _____________________
Certifier’s Name
First Name: ____________________ Middle initial: ____ Last Name: __________________
Business Name: _____________________________________________________________
Street: _____________________________________________________________________
City: ___________________________ County: __________________ Zip Code: __________
Telephone Number: ________________________ Fax: ______________________________
Email: ______________________________________________________________________
Certification/License Number: ___________________________________________________
Expiration Date: (mm/dd/yyyy): _________________________
Your Profession:
Doctor/Physician
Audiologist or Hearing Aid Specialist
Speech Pathologist
Other (Please describe) ____________________________________________________
Signature: _______________________________________________ Date: _________________
DDHH Equipment Distribution Program
PO Box 074, Trenton, NJ 08625-0074
Phone: 609-588-2648 or 800-792-8339, Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
July 2021 Page: 4
Equipment Distribution Program Form
NJ DDHH Conditions of Acceptance
I understand and agree to the following:
• The NJ DDHH is not responsible for my Wi-Fi telephone service or bills.
• If I change my address or phone number in New Jersey, I will provide updated information to NJ DDHH within 30
days.
• I will make arrangements to return my equipment in the event of my death.
• If I move to another state, I will contact NJ DDHH to arrange the return of equipment before I move. I will protect
the equipment from damage. I will be responsible for providing batteries, paper, and other consumable needs.
• If equipment is not working, I will NOT try to repair it or take it apart. I will contact NJ DDHH for instructions on returning the
equipment. Equipment, including all accessories, should be returned to the manufacturer in the original boxes if the warranty
has not expired.
• If equipment is reported as lost, a replacement will NOT be allowed.
• If equipment is returned and NJ DDHH determines it has been abused, a replacement will NOT be allowed.
• If equipment is stolen or damaged by someone other than me, I will report it to the police and provide a copy of
the report to NJ DDHH before a replacement is allowed.
• Equipment is the property of the State of New Jersey. I will not sell, pawn, give, or loan it to others outside my
household. If I do, I can be criminally prosecuted.
• If I am a minor, all equipment, obligations, and responsibilities will be transferred to me when I turn 18.
• It is against the law to file false statements regarding the application or equipment. If I do, I can be criminally
prosecuted.
• I agree to indemnify the State of New Jersey from any and all claims, damages, and expenses arising out of the
use or misuse of equipment by anyone or myself.
• If I fail to follow these Conditions of Acceptance, I can be denied the privilege of having equipment offered by
the NJ DDHH.
• A limit of one (1) smoke detector or baby alert system is provided through this program.
• Households must wait five (5) years before receiving another free phone.
Applicant’s Signature: ________________________________________ Date: ______________________
DDHH Equipment Distribution Program
PO Box 074, Trenton, NJ 08625-0074
Phone: 609-588-2648 or 800-792-8339, Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
July 2021 Page: 5
New Jersey Equipment Distribution Program Form
Items for the Equipment Distribution Program
The Gentex 7139 for wall mount is a photoelectric single station
smoke alarm designed to give reliable early warning of the
presence of smoke where both audible and visual alarms are
required. It is recommended that this item be paired with the
Sonic Alert HomeAware device.
The Nighthawk 900-0230 is a battery-operated carbon monoxide
alarm that provides reliable protection against the dangers of
carbon monoxide, and has a 7-year limited warranty. It is
recommended that this item be paired with the Sonic Alert
HomeAware device.
The Sonic Alert HomeAware Fire and CO Signaler (flashing strobe
light) - with built-in Smoke / CO listener, Phone, and Bed Shaker.
This device is for use with your smoke detector and/or CO2
alarm system.
The SadoTech Wireless Doorbell is perfect for apartments and
single-story homes. The indoor range is 500'. It has adjustable
volume and multiple tone options.
DDHH Equipment Distribution Program
PO Box 074, Trenton, NJ 08625-0074
Phone: 609-588-2648 or 800-792-8339, Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
July 2021 Page: 6
New Jersey Equipment Distribution Program Form
Items for the Equipment Distribution Program
The Panasonic KX-TGM450S with Volume Boost control for
amplified caller voice volume up to 50 dB, plus six-level voice
Tone Settings and a loud base unit Ringer.
The Geemarc Amplipower 60 Plus Amplified Telephone has a
receiver volume control of up to 67dB and an adjustable ringer
volume. The speaker offers clearer reception and tone control of
plus or minus 10 dB.
The Cisco Unified SIP Phone 3905 provides accessibility features
for the hard of hearing, blind, and mobility impaired. Because
many of these features are standard, they can be used by users
with disabilities without requiring any special configuration.
The CapTel 840 Plus gives you the flexibility to meet users'
telephone needs with just one device. It works with an analog
telephone line.
DDHH Equipment Distribution Program
PO Box 074, Trenton, NJ 08625-0074
Phone: 609-588-2648 or 800-792-8339, Fax: 609-588-2528
DDHH.communications2@dhs.nj.gov
July 2021 Page: 7
New Jersey Equipment Distribution Program Form
Items for the Equipment Distribution Program
The Minicom IV has an easy-touch keyboard with a bright, tilted
20-character display and includes a printer port to connect an
external printer.
VTech DM221 Digital Audio Baby Monitor is a simple, 2-piece
baby monitoring system that works great for deaf & hard of
hearing parents or caregivers
The Sonic Alert Traditional System BC400 Baby Cry Transmitter is
a wireless infant baby monitor alerts to baby's cries. It comes
with an adjustable baby cry sound sensitivity control and plugs
into any wall outlet.
The Sonic Blink wireless receiver, the BL300 has a built-in strobe
light, designed for signaling. This powerful signal receiver's
strobe light projects 360 degrees of flashing to remove blind
spots.
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Completed 17 December 2021

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