Loan Application Checklist

The following is required for both applicant and co-applicant (if applicable). Additional documents may be required.

A DocuDrop link will be emailed so that you can securely upload supporting documents.

You can also mail or fax the following items to complete your application:

Identification

Two copies of identification for applicant and co-applicant (if applicable); one must be a Photo ID.

Examples include:

Driver’s license with current address (Photo ID)
Non-driver’s ID with current address (Photo ID)
Passport (Photo ID)
Utility bill with current address
Medical insurance card
Social Security card

Current Proof of Income

Current proof of income for applicant and co-applicant (if applicable).

Examples include:

Two current paystubs and two most recent W-2s
IRS Tax Return for the past two years (if self-employed)
Supplemental Security Income (SSI) benefit verification letter
Social Security Disability Insurance (SSDI) benefit verification letter
Child Support/Alimony: You are not required to disclose income from alimony, child support, or separate maintenance payments unless you are using this as a basis for repayment of your loan.

Additional documentation may be required.

Assistive Technology Quote

Official vendor quote for the assistive technology (AT) being purchased.

The quote should include the following:

A breakdown of costs
Vendor contact information

AATLF Loan Application

AATLF loan application (all information in this form must be completed and submitted).

If you have a representative payee (rep-payee), be sure to read the section regarding rep-payee guidelines.

PLEASE NOTE: We do NOT reimburse for previously purchased items.

SECTION A – PRIVACY STATEMENT AND NOTICE

Your privacy is important to us, and maintaining your trust and confidence is one of our highest priorities. We respect your right to keep your personal information confidential and understand your desire to avoid unwanted solicitations. We are happy to provide this privacy policy notice, and we hope you will take a few minutes to read it. You will have a better understanding of what we do with the information you provide us and how we strive to keep it private and secure. This notice explains how we collect, handle, and disclose personal information about you.

Information We Collect

We collect non-public personal information about you from the following sources:

Information we receive from you on applications and other forms;

Information about your transactions with us or others; and,

Information we receive from a consumer credit reporting agency (i.e., credit bureaus).

Information We May Disclose

We do not disclose non-public personal information about our applicants or borrowers or former applicants or borrowers to anyone, except to our partner banks, the credit bureaus and as required by law.

Confidentiality and Security of Non-Public Personal Information

Confidentiality and security of your non-public personal information is of paramount importance to us. We maintain physical, electronic, and procedural safeguards in compliance with all applicable laws and regulations to guard your non-public personal information from unauthorized access, alteration, and destruction. We restrict access to your non-public personal information to those employees and other parties who must use the information to provide services to you.

Privacy Notice Confirmation*

By checking this box, I confirm that I have read and understand PATF’s Privacy Statement and Notice.

Telling Your Story*

We may use your “story” (for example, why you needed a loan, what equipment or technology you purchased, and how it impacted your life) to explain and market our program to other borrowers and contributors. However, we will not identify you by name unless you give us permission to do so. If you do not wish to have your story told, please indicate below. It will not affect your loan eligibility.

Yes, you may use my story

No, please do not use my story

SECTION B – LOAN REQUEST

Check the appropriate box:*

You are applying for individual credit in your own name and are relying on your own income or assets for repayment of the credit requested.

You are applying for joint credit with another person.

Required information for PATF to process your application:

Amount Requested*

What are you purchasing?*

SECTION C – APPLICANT INFORMATION

Full Name*

First Last

Date Of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

How long at this address?*

Email Address*

Home Phone Number:

Cell Phone Number:

Number of People in Your Household (Related & Unrelated):*

Driver's or Non-Driver's ID No.:*

ID Expiration Date:*

What is your country of citizenship?*

What is your citizenship status?*

U.S. Citizen

Permanent Resident of U.S.

Other

Please explain your citizenship status.*

Previous Street Address (if less than two years):

Street Address City State / Province / Region ZIP / Postal Code Country

Current Employer:

Work Number:

Your Position or Title:

Years/Months Employed:

Employer's Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Previous Employer (if less than two years):

Previous Employer's Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Nearest relative or other party not living with you:

Name*

First Last

Relationship:*

Nearest Relative's Address:*

Street Address City State / Province / Region ZIP / Postal Code Country

Nearest Relative's Telephone Number:*

SECTION D – CO-APPLICANT INFORMATION (IF APPLICABLE)

Full Name

First Last

Date of Birth:

Current Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

How Long at This Address:

Email Address:

Home Phone Number:

Cell Phone Number:

Driver's or Non-Driver's ID No.:

ID Issue Date:

ID Expiration Date:

What is your country of citizenship?

What is your citizenship status?

U.S. Citizen

Permanent Resident of U.S.

Other

Please explain your citizenship status.

Previous Street Address (if less than two years):

Street Address City State / Province / Region ZIP / Postal Code Country

Current Employer:

Work Number:

Your Position or Title:

Years/Months Employed:

Employer's Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Previous Employer (if less than two years):

Previous Employer's Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Nearest relative or other party not living with you:

Name

First Last

Relationship

Nearest Relative's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nearest Relative's Telephone Number:

SECTION H – REVIEW AND SIGN

AUTHORIZATION

I/We understand and agree that any information provided to or otherwise collected by Pennsylvania Assistive Technology Foundation (PATF) or its wholly owned subsidiary, Appalachian Assistive Technology Loan Fund (AATLF) may be provided to one or more lenders (each, a “Lender”) in connection with my/our request for financing.

I/We authorize PATF to share any and all information with any Lender, and also authorize such Lender to share any and all information regarding me/us, any loan application and any loan (including, without limitation, loan status) referred to such Lender by PATF with PATF and its representatives.

I/We acknowledge and agree that each Lender, its agents, successors and assigns are third-party beneficiaries having the right to enforce the authorizations and certifications contained within this Application, and to exercise any rights and remedies to which they may be entitled at law or in equity.

CREDIT REPORT AUTHORIZATION

As part of your application for an extension of credit (“loan”) through Pennsylvania Assistive Technology Foundation (PATF) or its wholly owned subsidiary, Appalachian Assistive Technology Loan Fund (AATLF), an approved PATF Lender requests your authorization to pull your credit report, including, but not limited to, your personal credit profile and other information on file at one or more consumer reporting agencies (“credit report”). You understand you are providing “written instructions” to the approved PATF Lender under the Fair Credit Reporting Act which authorizes the Lender to procure your credit report from one or more consumer reporting agencies. You authorize the Lender to verify information in your application and agree that the Lender may contact third parties to verify such information. The Lender may use your credit report(s) to authenticate your identity, to make credit decisions, and for related purposes.

FULL LEGAL SIGNATURE OF APPLICANT*

First Middle Last

DATE*

FULL LEGAL SIGNATURE OF CO-APPLICANT

First Middle Last

DATE

*IMPORTANT: If you have a Representative Payee and the Representative Payee is a family member, that person must be a co-applicant on the loan. By signing as a co-applicant, the rep-payee agrees that he/she is responsible for making the loan payments as he/she would make any payment on behalf of the beneficiary. If the applicant is no longer able to repay the loan the co-applicant would be responsible for paying the remainder of the loan balance.

SECTION I – CERTIFICATION

I/We understand that this is a request for funds that I/We will need to repay. I/We authorize Pennsylvania Assistive Technology Foundation (PATF) or its wholly owned subsidiary, Appalachian Assistive Technology Loan Fund (AATLF) to review all information provided and seek additional information from third parties required to verify the contents of this application. All information is true and correct and is provided to obtain the loan I/we am/are seeking. Any misrepresentation on any part of this application could result in rejection of this application or termination of the loan.

I/We certify that the information provided in this application is true and correct as of the date set forth opposite my/our signature on this application and acknowledge my/our understanding that any intentional or negligent misrepresentation of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001 et seq., and liability for monetary damages to PATF, any other lender, its agents, successors, assigns, insurers, and any other person who may suffer any loss due to reliance upon any misrepresentation I/we made in this application or in any other manner.

I/We further understand that issuance of a loan does not imply any type of warranty by PATF or any other lender regarding the suitability, condition, merchantability or safety of the device or equipment that I/we purchase with the loan. I/We understand that I/we alone are responsible for selecting the devices or equipment to be financed. Therefore, I/WE CAN MAKE NO CLAIMS AGAINST PATF OR ANY LENDER OR ANY OF THEIR AGENTS, AND I/WE EACH HEREBY RELEASE PATF AND ANY OTHER LENDER, AND ALL OF THEIR RESPECTIVE AGENTS, FROM AND AGAINST ALL LIABILITY, FOR DEFECTS IN ANY DEVICE OR EQUIPMENT OR ANY ACCIDENT OR INJURY RESULTING FROM ITS USE.

I/We hereby also authorize PATF or its wholly owned subsidiary AATLF and any lender to whom PATF may refer this application to disclose to PATF any information about any of us that the lender obtains or compiles that may be relevant to decisions PATF may make with respect to the application.

FULL LEGAL SIGNATURE OF APPLICANT*

First Middle Last

DATE*

FULL LEGAL SIGNATURE OF CO-APPLICANT

First Middle Last

DATE

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT

Why are we asking for this information? To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

Identify the name of the official, office held, and country:*

Comments

This field is for validation purposes and should be left unchanged.

Loan Application Checklist

Identification

Current Proof of Income

Assistive Technology Quote

AATLF Loan Application

SECTION A – PRIVACY STATEMENT AND NOTICE

Information We Collect

Information We May Disclose

Confidentiality and Security of Non-Public Personal Information

SECTION B – LOAN REQUEST

Required information for PATF to process your application:

SECTION C – APPLICANT INFORMATION

SECTION D – CO-APPLICANT INFORMATION (IF APPLICABLE)

SECTION E – MARITAL STATUS

APPLICANT

CO-APPLICANT (IF APPLICABLE)

SECTION F – INCOME & EXPENSES

APPLICANT

Assets (Optional)

CO-APPLICANT (IF APPLICABLE)

ASSETS (Optional)

APPLICANT MONTHLY EXPENSES

SECTION G – ASSISTIVE TECHNOLOGY AND USER

INDIVIDUAL WITH DISABILITY

DISABILITY/ASSISTIVE TECHNOLOGY INFORMATION

DEMOGRAPHIC INFORMATION OF THE ASSISTIVE TECHNOLOGY USER

SECTION H – REVIEW AND SIGN

AUTHORIZATION

CREDIT REPORT AUTHORIZATION

SECTION I – CERTIFICATION

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT

AATLF Application

Loan Application Checklist

Identification

Current Proof of Income

Assistive Technology Quote

AATLF Loan Application

SECTION A – PRIVACY STATEMENT AND NOTICE

Information We Collect

Information We May Disclose

Confidentiality and Security of Non-Public Personal Information

SECTION B – LOAN REQUEST

Required information for PATF to process your application:

SECTION C – APPLICANT INFORMATION

SECTION D – CO-APPLICANT INFORMATION (IF APPLICABLE)

SECTION E – MARITAL STATUS

APPLICANT

CO-APPLICANT (IF APPLICABLE)

SECTION F – INCOME & EXPENSES

APPLICANT

Assets (Optional)

CO-APPLICANT (IF APPLICABLE)

ASSETS (Optional)

APPLICANT MONTHLY EXPENSES

SECTION G – ASSISTIVE TECHNOLOGY AND USER

INDIVIDUAL WITH DISABILITY

DISABILITY/ASSISTIVE TECHNOLOGY INFORMATION

DEMOGRAPHIC INFORMATION OF THE ASSISTIVE TECHNOLOGY USER

SECTION H – REVIEW AND SIGN

AUTHORIZATION

CREDIT REPORT AUTHORIZATION

SECTION I – CERTIFICATION

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT

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