Instructions for Completing the Application

Please take a moment to review these instructions for completing the attached Pennsylvania Assistive Technology Foundation (PATF) Loan Application. To insure that your loan will be processed in a timely manner, be sure to submit all the required documentation listed below. Please note that your application cannot be fully processed until all of your documentation has been received.

NOTE: This application is for Pennsylvania residents ONLY.

1. Complete all pages of the application form.

2. Detach and read the “Privacy Rights Notice.” Keep this notice for your records.

3. If you choose not to respond to a question labeled “optional” check the “no response” box.
If a question is not applicable (NA) to you, draw a line through it or write “NA” next to the question. This will indicate that you have read the question and did not inadvertently skip the question.

4. Mail or fax an official quote from your vendor, providing a breakdown of costs and vendor’s address and phone number. If you are purchasing a used AT device from another consumer, please include a letter listing the price of the device.

5. Mail or fax Proof of Income—examples of income include:

  1. 1. Paystub from your Employer
  2. 2. IRS Tax Return for the past two years (if self-employed)
  3. 3. Supplemental Security Income (SSI) Award Letter or Verification Letter
  4. 4. Other Reportable Income you would like to be considered for your ability to repay a loan
  5. 5. Child Support/Alimony: You are not required to disclose income from alimony, child support, or separate maintenance payments.
  6. 6. Co-applicant’s proof of income

6. Mail or fax a copy of two forms of identification; a picture ID and one other form.

  1. 1. Driver’s License (Picture ID)
  2. 2. Non-driver’s identification (Picture ID)
  3. 3. Passport
  4. 4. Utility bill with current address
  5. 5. Medical card

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
Why are we asking for this information? To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.