ATF Eligibility Determination Application (word doc)

To determine eligibility for an Access to Telework Fund (ATF) low interest loan and/or low interest guaranty loan, the loan applicant must complete and return this Eligibility Determination Application to Oklahoma ABLE Tech. Upon receiving this completed Eligibility Determination Application, Oklahoma ABLE Tech may determine an Oklahoman with a disability or a person that has a dependent with a disability, eligible to apply for a bank loan based on the applicant’s description (question #5 below) to have a telework outcome.

Telework outcomes can encompass work that can be performed effectively from home and/or remote sites away from the office, such as work on the road or at a telework center. Telework would apply to individuals with disabilities who are unemployed, underemployed, self-employed or needing to maintain employment on a full time or part time basis.

1. Applicant’s legal name:

2. Type of disability:

3. Description of equipment being requested and how it will enable the person with a disability to telework:

4. Are you currently

____Unemployed

____Employed (salaried from employer). Number of work hours per week____ Number of these hours per week Teleworking ____

Type of work you perform _____________________________

____Self employed Number of work hours per week____ Number of these hours per week Teleworking ____
Type of work you perform _________________________________

5. What is your teleworking goal? (Check all that apply.)

____ Become newly self-employed
____ If currently Teleworking, to increase Telework hours

____ Become newly employed in Telework for an employer
____ If currently Teleworking, increase Telework salary

____ Prevent Unemployment?

____Other goal, please describe._______________________________________________________

6. Amount of loan request including costs of equipment purchase, extended warranty, service agreement, insurance, training, maintenance and repair: _______________________________________________

7. Have you ever applied for services from the Department of Rehabilitation Services?

Yes No Don’t know

Please complete and send the following documentation with the ATF Eligibility Determination Application:

Documentation verifying your disability. Documentation examples include: a disability benefits award letter, a written statement from a licensed physician, or other licensed professional.
Signed statement authorizing release of information about the applicant between Oklahoma ABLE Tech, BancFirst of Stillwater, and Oklahoma Assistive Technology Foundation.
BancFirst Consumer Credit Loan application.

Upon review of the completed ATF Eligibility Determination Application, disability verification documentation, BancFirst Consumer Loan Application and signed Release of Authorization form, Oklahoma ABLE Tech will determine eligibility. If the applicant is determined eligible for the ATF, ABLE Tech will notify applicant and automatically forward the completed BancFirst Consumer Credit Application to Debbie Thomas, BancFirst of Stillwater, who then will process the loan application. If applicant is not determined eligible for the ATF program ABLE Tech will notify applicant in writing.

Although you may meet the requirements for eligibility for the ATF, it does not mean that you qualify for a BancFirst low interest loan or an Oklahoma Assistive Technology Foundation low interest guaranty loan.

Once ABLE Tech forwards the consumer loan application to BancFirst of Stillwater, they will approve or decline the loan application, and report the decision to the applicant (in writing), the Oklahoma Assistive Technology Foundation and to Oklahoma ABLE Tech. For approved loans, BancFirst will provide the borrower with instructions on any needed documentation required to close the loan.

If BancFirst denies the loan application they will forward all financial information to the Oklahoma Assistive Technology Foundation (OkAT). If the borrower wants to pursue a guaranty loan request the borrower must complete an additional loan report and monthly expense sheet that will be provided to them at that time. Upon receiving the completed loan report and monthly expense sheet, the OkAT Board will meet within 5 business days and report the decision to the applicant and to BancFirst of Stillwater.

Prior to approval of a guaranty loan, that is using potential or current self-employment income to purchase new equipment, the applicant may be required to submit a self-employment business plan. At a minimum the plan must include:

Complete description of the proposed business
Business objectives
Ownership
Marketing analysis and plan
Financial management plan including personal finance sheets, projected expenses and income for a least 2 years
Specific listing of needed new costs and equipment

OkAT will refer applicants to programs and services across the state that may assist the individual with the self-employment business plan.

If you have any questions you may contact:

Shelley Gladden
Oklahoma ABLE Tech
1514 W. Hall of Fame
Stillwater, OK 74078
888-885-5588
405-744-2487 FAX

updated 7.1.12