Apply Now – iPad – Speech Disabled

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:

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 Number *

Please Note:

YOU WILL BE CONTACTED BEFORE YOUR APPLICATION CAN BE APPROVED

Cell/Text number

Last 4 Digits of Social Security # *

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

Pics of choices

Equipment Options *iPad Air (64GB) / 9.8 x 6.8 inchesiPad Mini (64GB) / 8 x 5.3 inchesChoose one of the models listed above. Limit one per household and at least four years before applying for new replacement.

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)

List of Responsibilities

• LIMIT ONE TABLET PER HOUSEHOLD

• Tablet is property of InTRAC for the first four years. It is laser etched on the back with the “Property of InTRAC”.

• After four years, you may re-apply for a new tablet. Tablet is for telecommunication purposes.

• Tablet arrives pre-loaded with apps for your specific needs.

• You are responsible for using and maintaining tablet.You understand that InTRAC can remotely shut off and lock the tablet if it is suspect of being used outside the state of Indiana, except for vacations.

• You understand to contact Teltex Technical support at 1-888-515-8120 for iPad tablet, or Rz Mobility Support at 1-800-729-0083 for Android tablet, if you experience any problems or have any questions.

• You understand if the equipment is broken or damaged through misuse or negligence, you are financially responsible for ALL costs related to repairing or replace the equipment.

• You are responsible to provide InTRAC with a fire or police report in case of fire or theft.

Responsibilities

Yes, I understand and agree to my responsibilities below when borrowing equipment from InTRAC.

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.

Apply Now – iPad – Speech Disabled

ELIGIBILITY

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

Is your annual income below $74,000? *

Do you have WiFi/Mi-Fi or Hot Spot? *

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

How did you hear about us?

Responsibilities