Apply Now – Relay Indiana

We’re excited to help all Hoosiers stay connected. Fill out the online form below.

Go to Relay Indiana homepage / Click here

ELIGIBILITY

To be eligible for the Relay Indiana program, you must meet the following criteria:

Are you a resident of the state of Indiana? *YesNo

Is your annual income below $74,000? *

YesNo

Check which disability group(s) best defines applicant's disability *

DeafHard of HearingSpeech Impairment

Name *

Street Address *

Apartment, suite, etc

City

State (Indiana Residents Only)If you do not live in Indiana, please go to your state's website

ZIP Code

Phone

Cell/Text phone

Email Address

Date of Birth

GenderMaleFemalePrefer not to answerGender questions are optional at the discretion of the applicant.

Name of alternate contactWho else can we contact to reach you?

Phone of alternate contact

Equipment Details

CapTel 840 – This phone works like any traditional telephone, but it also shows you written captions during your telephone conversations. Read more

CapTel 840i – This captioned telephone shows captions of everything your caller says on an extremely large display screen to help make sure you catch every word. Read more

CapTel 2400i – It makes it easy to enjoy phone conversations, confident you’ll catch every word. Designed for people with low vision or who have difficulty reading standard-sized captions. Read more

CapTel 880i – This remarkable phone works like any traditional telephone, but it also connects to the Internet to show you written captions during your telephone conversations. Read more

SuperPrint 4425
TTY (text telephone – also known as Telecommunications Device for the Deaf/TDD). Used to type a message to another TTY user or a person using a standard telephone through the relay service. Read more

Uniphone 1140
Voice Carry-Over/Hearing Carry-Over/Text Telephone (VCO/HCO/TTY). Used as standard telephone, VCO, HCO, or TTY. Allows you to listen to the caller and type reply on the telephone keypad. Read more

Equipment Options *CapTel 840 (analog LANDLINE phone required)CapTel 840i (Internet required)CapTel 880i (Internet required)CapTel 2400i (Internet required)Superprint4425 (analog LANDLINE phone required)Uniphone1140 (analog LANDLINE phone required)Choose one of the models listed above. Limit one per household and at least four years before applying for new replacement.

Flashing Light SignalerYesNo

Total income:

Upload proof of income

No file chosen

Provide proof of financial information such as Federal Tax For 1040, Social Security letter, or paycheck stub. (You may blackout your SSN)

Responsibilities

Yes, I understand and agree to my responsibilities below when borrowing equipment from InTRAC.If the equipment is stolen or damaged by fire, you must report the theft or damage to your local police. You are required to mail a copy of the report to InTRAC within five (5) days. If the equipment is damaged, lost, or destroyed because of carelessness or misuse by you or persons known to you, you are required to pay for the repair or replacement of the equipment. You need to understand what qualifies as "carelessness or misuse", including, but not limited to: Using the wrong type battery; damage due to being dropped; Food or liquid spills inside the machine; Tampering with or trying to fix equipment yourself; Insect infestation which destroys the circuits.

SignatureBy signing, I affirm the information provided is complete and correct to the best of my knowledge. I declare under penalties of perjury that the information above is true.

ELIGIBILITY

To be eligible for the Relay Indiana program, you must meet the following criteria:

Is your annual income below $74,000? *

Check which disability group(s) best defines applicant's disability *

How did you hear about us?

Responsibilities