Equipment Distribution Program Eligibility Application

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

New Jersey Department of Human Services

Division of the Deaf and Hard of Hearing

Equipment Distribution Program

Eligibility Application

The New Jersey Division of the Deaf and Hard of Hearing (DDHH) provides free assistive

devices to deaf or hard of hearing individuals through the Equipment Distribution Program

(EDP). Since 1993, the DDHH has operated this program to ensure that New Jersey residents

with hearing loss have access to critical telecommunications and vital home safety alerting

equipment. Upon meeting program eligibility, individuals receive communication devices at no

cost.

Program Eligibility:

 Must have hearing loss

 Must be a New Jersey resident

 Total combined household income must not be greater than 400% of the federal poverty

level.

Please complete the application using the checklist below:

☐ A copy of ONE (1) document from List A to establish residency and identity. (Page 2)

☐ OR a copy of ONE (1) document from List B to establish identity AND a copy of ONE (1) document to

establish residency. (Page 2)

☐ Applicant’s signature (Page 2)

☐ Include email address for UPS tracking updates (Page 3)

☐ Certification of Disability completed by treating provider, with signature. (Page 4)

☐ Review of Conditions of Acceptance, with signature. (Page 5)

☐ Items selected (Pages 6-9)

☐ Joint or individual copy of most recent tax return or W2s showing household income or a letter from

your Employer or Award Letter from a Social Service Agency or US Department of Veterans Affairs.

☐ Submit application by mail, fax, or email:

DDHH Equipment Distribution Program

PO Box 074

Trenton, NJ 08625-0074

Fax: 609-588-2528

Email: DDHH.communications2@dhs.nj.gov

Number of people living in household

2024 Federal Poverty Guidelines

$60,240

$81,760

$103,280

$124,800

$146,320

*For each additional person, add $21,520

Source U.S. Department of Health and Human Services

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

SECTION 1: Please provide a copy of one (1) document from List A OR a copy of one (1) document

from List B AND a copy of one (1) document from List C.

List A

Documents that establish both

identity and residency

Please select one from the list

below

 NJ or Municipal ID card

 NJ Driver's License

 NJ Student ID

 Utility, cell phone, or

internet bill

 Bank/insurance statement

 Tax Returns, last two years

 Paystub from employer

 Rent receipt, lease,

mortgage

 Letter from social service

agency

 Letter from health care

provider

 Letter from government

agency

List B

Documents that

establish identity

Please select one from the

list below

 Student ID card

 Student

Transcript

 Passport

 Birth Certificate

 Driver License

from another

country

 Consulate ID

card

 A child's U.S.

birth certificate

and your name

 Letter from IRS

or ITIN

 Marriage

Certificate

 Divorce Decree

 U.S. court

document

List C

Documents that

establish residency

Please select one

from the list below

Signed and dated

letter including the

full name and

phone number of

the individual

writing the letter

from one of the

following:

•

Landlord

•

Representative

of worship

•

Medical

provider

•

Service

provider

•

Shelter

acknowledging NJ

residency

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

Application Form

SECTION 2: This form will be scanned for computerized data capture. Please follow the instructions to

ensure that the application is processed quickly and accurately.

 Use blue or black ink only.

 Print clearly, in uppercase letters.

 Correct errors with white correction fluid.

First Name: _______________________________ Middle Initial: _____

Last Name: _______________________________

Telephone Number: ________________________

Check one: ☐ Cell ☐ Home ☐ Videophone

Email Address: ____________________________

IMPORTANT: Email addresses will be used to provide UPS tracking updates.

How do you identify: ☐ Deaf ☐ Hard of Hearing

Check one: ☐ Mild ☐ Moderate ☐ Profound ☐ Unable to speak or sign

Mailing Address

Street: ___________________________________ City: _______________________

County: __________________________________ Zip Code: ______________

Physical Address (if different from Mailing Address)

Street: ___________________________________ City: _______________________

County: __________________________________ Zip Code: ______________

I certify to the best of my knowledge that I meet the program’s eligibility requirements and the

information in this application is true and correct.

Applicant’s Signature: Date:

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

New Jersey Equipment Distribution Program Form

Certification of Disability

SECTION 3: This portion of the application must be completed by a treating service provider. Provider,

please verify and certify that the applicant will benefit from the use of the requested technology.

This form will be scanned for computerized data capture. Please follow the instructions to ensure that

the application is processed quickly and accurately.

 Use blue or black ink only.

 Print clearly, in uppercase letters.

 Correct errors with white correction fluid

Applicant’s Name: ___________________________________

Provider’s Information:

First Name: _______________________________ Middle Initial: _____

Last Name: _______________________________

Business Information:

Street: ___________________________________ City: _______________________

County: __________________________________ Zip Code: ______________

Telephone Number: ________________________ Fax Number: __________________

Email Address: ____________________________

Certification/License Number: ______________________________

Expiration Date (MM/DD/YY): ______________________________

Provider’s Profession:

☐ Doctor/Physician

☐ Audiologist

☐ Hearing Aid Specialist Speech

☐ Pathologist

☐ Other (please describe):

_____________________________

Signature _______________________________________ Date: ___________________

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

Conditions of Acceptance

SECTION 4: Please review the following section in its entirety.

I understand and agree to the following:

 Equipment is the property of the State of New Jersey. I will not sell, pawn, give, or loan the

equipment to individuals outside of my household. If I do, I understand I can be criminally

prosecuted.

 The NJ DDHH is not responsible for service plans or bills associated with equipment.

 I will protect the equipment from damage.

 If the equipment is not working, I will NOT try to repair it or take it apart. I will contact DDHH for

instructions on returning the equipment. Equipment, including all accessories, should be returned

to the manufacturer in its original box if the warranty has not expired.

 If the equipment is returned and NJ DDHH determines it has been damaged, a replacement will

NOT be allowed.

 If the equipment is reported as lost, a replacement will NOT be allowed.

 If the equipment is stolen or damaged by someone other than me, I will report it to the police and

provide a copy of the police report to NJ DDHH before replacement is allowed.

 It is against the law to file false statements. If I provide false statements in this application or

regarding equipment, I understand I can be criminally prosecuted.

 I agree to indemnify the State of New Jersey from any and all claims, damages, and expenses

that arise out of the use or misuse of equipment by myself or anyone else.

 If there is a change in address or phone number, I will provide the new information to NJ DDHH

within 30 days.

 If I move to another state, I will contact NJ DDHH to arrange the return of equipment before I

move.

 If I am a minor, all equipment, obligations, and responsibilities will be transferred to me when I

turn 18.

 I will make arrangements to return my equipment in the event of my death.

 Households must wait five (5) years before receiving another phone through this program.

 A limit of one (1) smoke detector or baby alert system is provided within this program.

 If I fail to follow these Conditions of Acceptance, I can be denied the benefit of having equipment

offered by the NJ DDHH.

Applicant’s Signature: _______________________________ Date: __________________

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

Items Available Through EDP

The Sonic Alert HomeAware Fire and CO Signaler is a

flashing strobe light with a built-in smoke / CO listener,

phone, and bed shaker. This device is for use with

existing smoke detector and/or CO2 alarm system.

The Nighthawk 900-0230 is a battery-operated carbon

monoxide alarm that provides reliable protection

against the dangers of carbon monoxide, and has a 7-

year limited warranty. It is recommended that this item

be paired with the Sonic Alert HomeAware device.

The Ring Video Doorbell 2 is a smart security system

that can be monitored from anywhere. The doorbell is

battery powered with the option to hardwire and comes

with a rechargeable battery pack.

The Sonic Alert is perfect for smoke alerts in other

rooms. This does not replace existing smoke

detectors. This will pair well with the HomeAware alert

listener system.

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

Items Available Through EDP

The Clarity XLCR Amplified Cordless Extra Loud

(50dB) phone with tone control including 4 settings,

boost button, and volume control wheel to give provide

a customized listening experience

The Geemarc Amplipower 60 Plus Amplified

Telephone has a receiver volume control of up to 67dB

and an adjustable ringer volume. The speaker offers

clearer reception and tone control of plus or minus 10

dB.

The Cisco Unified SIP Phone 3905 provides

accessibility features for the hard of hearing, blind, and

mobility impaired. Because many of these features are

standard, they can be used by users with disabilities

without requiring special configuration.

IMPORTANT: Unfortunately, the CapTel 840+ is no longer in service. Please contact Customer Service

at CapTel for more information. Captel can be reached via phone at (888) 269-7477, email

[email protected], or visit www.CapTel.com. Individuals who currently have the CapTel 840+ may

contact CapTel to request an upgrade to an internet model.

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

Items Available Through EDP

The Minicom IV has an easy-touch keyboard with a

bright, tilted 20-character display and includes a printer

port to connect an external printer.

VTech DM221 Digital Audio Baby Monitor is a simple,

2-piece baby monitoring system that works great for

deaf & hard of hearing parents or caregivers

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

Choose ONE from this list:

Tablet - Apple iPad Wi-Fi Only 64GB

* Requires Access to Internet Service.

Tablet - Samsung Galaxy S6 Lite Wi-Fi Only

64GB *Requires Access to Internet Service.

Smartphone - Apple iPhone XR Wi-Fi & 4G

64GB *Requires Cellular Service Plan.

Smartphone - Google Pixel 5a Wi-Fi & 4G

128G B *Requires Cellular Service Plan.

IMPORTANT:

If a Smartphone is selected, the individual must agree to get a cellular service plan from a provider. The

tablets are Wi-Fi only and do not require a service plan. All Smartphones offered in this program are

“unlocked” so that the individual may choose a service provider of their choice.

For individuals who need low-cost internet service there may be an option through the FCC

Emergency Broadband Benefit - https://www.fcc.gov/broadbandbenefit

The device will come with the following deaf and hard of hearing accessible apps pre-installed:

Division of the Deaf and Hard of Hearing

New Jersey Equipment Distribution Program

IP Relay, Video Relay Service, IP Captioned Telephone Service, Video Calls & Video

Messaging.

All devices include a 3-year warranty. DDHH does not provide cases. We urge you to

purchase a protective case for the device selected. These devices are subject to breakage if

they are dropped. DDHH will not replace a device that is damaged due to breakage.

SECTION 5: If you are assisting someone else in completing this application, please complete the

following portion.

This form will be scanned for computerized data capture. Please follow the instructions to ensure that

the application is processed quickly and accurately.

 Use blue or black ink only.

 Print clearly, in uppercase letters.

 Correct errors with white correction fluid

1. Please check one of the following boxes regarding relationship to the applicant.

☐ Family Member

☐ Friend

☐ Attorney

☐ Agency

☐ Advocate

☐ Social Worker

☐ Other (please specify):

_________________

Last Name: _______________________________ Suffix (Jr., Sr., etc.): ________

First Name: ___________________________ Middle Initial: ____

Street Address: _______________________________________

City: ________________________________ State: ______ Zip Code: _________

Preparer’s Signature: _________________ Phone Number: ____________________

PLEASE SUBMIT THE FORM BY:

MAIL:

Division of the Deaf and Hard of Hearing

Equipment Distribution Program

PO Box 074

Trenton, NJ 08625-0074

EMAIL:

[email protected]

OR FAX:

(609) 588-2528

FOR MORE INFORMATION, CALL:

(609) 588-2648

(800) 792-8339

(609) 503-4862 videophone