Have You Applied to Any Other Organiza- Tions Regarding This Claim

Savings Acct.Amt:

Have you applied to any other organiza- tions regarding this claim:

Name of Social Worker or other Individual who may assist us with your claim:

Colonial Chapter

ParalyzedVeteransof America

Yes

Who:

NamePhone#

As a recipient of this program, I agree to hold harmless and discharge the association, namely, Colonial Chapter of the Paralyzed

700 Barksdale Rd., Unit 7

Newark,DE19711 (302)861-6671/888-963-6595

Are you a client of Vocational Rehabilita-

tion:

YesTraditional:IndependentLiving:

Otherfundingprogram: (ex: UCP, VA,DSAAPD)

Have you applied to Colonial PVA (formerlyDE-MDPVA)forassistancein thepast:

YesNoYear:

(approximate)

Comments or remarks:

Veterans of America, a Delaware non-profit organization, their assigns, lessees, agents, employees, directors, and volunteers and any and all claims, damages, demands, actions, costs and/or expenses by or on our behalf arising out of personal injury, property dam- age, and/or accidents which may be incurred by you upon acceptance of said item received.

Name (signature)

SS#:

I hereby certify that the above information Is correct to the best of my knowledge.

************************************************* FOR OFFICIAL USE ONLY

APPROVED:

NOTAPPROVED: DATE:

(302)861-6675 FAX

Application for DELAWARE ProstheticFund

This application does not cover the cost of medication, eye glasses or any other item which we determine to be unacceptable.

The requested item may be funded solely by the Colonial Chapter’s Prosthetics Fund or you may be responsible for a percentage of the total cost, based upon your income and ability to raise funds from other sources.

Application must be completed in its en- tirety & you MUST include proof of in- come or application will be returned to you.

Date: Name: Address:

Areyouemployed:YESNO

If yes,AnnualIncome: Employer Address &Phone:

MONTHLY HOUSEHOLD INCOME:

SocialSecurity: (SSDI,SSI)

Pension/Retirement:

Phone:

Workman’sComp:

Stocks,Bonds:

MaritalStatus:

DateofBirth: YourDisability: WheelchairUser?(check.one):N/A ManualPowerScooter

Rent or Own Residence:

RentOwn Do you live withParent/Guardian:

YesNo If yes, state parentincome:

Annuity,Interest: Aid forDependentChildren: Other: TOTAL:

What do you need? (ex. Ramp, Lift, Wheelchair, etc.):

Are you aU.S.Citizen?: Are you a Veteran:Yes No ServiceConnected/NonSC: DoyoureceiveVeteransPension

or Compensation?: Amt:

# ofDependents:

Spouse’sIncome: Other household income: Health Insurance Type &Policy:

N/A

HaveyouappliedtoInsuranceProviderfor the Requesteditem:

YesNo

If Yes, provide documentation. If no, please explain why you have notapplied:

MONTHLY HOUSEHOLD EXPENSES:

Rent/Mortgage: Food: Utilities: Insurances: MedicalExpenses: Other(Listseparate): TOTAL: