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  - - HAP Ramp Specifications
  - - HAP Bathroom Specifications
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Application for Independent Living Resources Programs

Sue Williams Freedom Fund Program (SWFF)

and

Home Access Program (HAP)

Please use this form to apply for the Independent Living Resources Program.
These programs are available to Vermont residents only.

Items with an asterisk (*) are required.

Alternatively, you may download the applicaiton as a PDF file (PDF 48K).
If you do not have the Adobe Acrobat Reader, you may download it here.

Application For:
*Choose Program(s)	Sue Williams Freedom Fund Program (SWFF) Home Access Program (HAP) Please note that income limits apply for the HAP Program. Pleae view income limit chart for details.
Application Information
*First Name
*Last Name
*Address
*City
*County
State	Vermont
*Zip Code
Contact Person & phone # (if other than self)
*Birth Date
*Gender	Female Male
*Veteran?	No Yes
*Vocational Rehab?	No Yes
Insurance Information
*Select Type(s) of Health Insurance	Medicaid Medicare Other If other, please specify: Other
*Are you currently participating in a Waiver Program?	No Yes If yes, what Waiver is it? Dept. of Aging and Disabilities - Choices for Care Developmental Services (DS) Waiver The Traumatic Brain Injury Waiver The Mental Health Waiver Katie Beckett Waiver Other If other, please specify: Other waiver:
Ethnicity Information (optional):
Not reporting Hispanic or Latino Not Hispanic or Latino
Race Information (optional):
Not reporting White Hispanic or Latino Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaskan Native
Additional Information
*What is your Disability?
*Functional limitations to independence (such as unable to walk, dress self, etc.):
*Annual household income (include all income in household)	$ Please user only numbers (no commas, dollar signs, or decimals)
*How many people living in your household?
*Source of income:	SS SSI SSDI Other If other, please specify other income source
*Do you rent or own?	Rent Own If you Rent is it Private Rent or Subsidized Rent? Private Rent Subsidized Rent If you Own, What year was your house built?
*Do you have a working smoke detector in your home?	Yes No If yes, how many?
*Do you have a fire extinguisher that you can use yourself?	Yes No
*Living Arrangement (select one)
Institution Specify institutution Dependent with family and/or friends Assisted Living Independent Other If other living arrangment, please specify
*Program Goals (please choose at least one for each program you are applying for)
Home Access Program (HAP) Goals	Bathroom Modifications Ramp/Entrance Lift related to bathroom or entrance Ceiling track related to bathroom or entrance
Sue Williams Freedom Fund (SWFF) Goals:	Personal Assistance Equipment If equipment, please specify Other If other goal, please specify
Statement
*Please describe how this equipment/service will help increase your independence and how it relates to your disability.
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