APPLICANT LOAN REPORT

1. What is your disabling condition?

2. What type of assistive technology do you want to purchase? Give any details you have on the device, for example: make, model, year and price.

3. Why do you think you need this device?

4. What is your current adaptive method?

5. What is your current residential situation? Are you purchasing a house, own, or rent? How long have you lived at that address?

6. Do you have medical insurance; if so, who is your insurer?

7. Are you on a Medicaid Home and Community Based Waiver such as ADvantage?

8. Do you have any support or assistance in the home, for example: a spouse, family member and or in-home assistance care?

9. You have listed all of your current financial obligations on the Monthly Expense Sheet. Do you have any other obligations not listed? If so, please explain.

10. Do you have any bad debt? Are you making any payments toward those debts?

11. Have you sought any other type of funding source for the item you would like to purchase through this low interest loan?

12. Other comments, if you would like to explain anything else on this guarantee loan request.