Modification Access Project (MAP) This is a partial funding program and most requests do not exceed $1800 ____________________________ Homeowner/Renter’s Name & Address Name: (required) Address: (required) City: (required) State: (required) New Jersey Zip: (required) Phone number: (required) CellHome Phone number: CellHome Email: Date of birth: (required) Veteran? (required) YesNo Check ✓ all that apply: Disability? (required) YesNo (Specific) Senior? (required) YesNo How many people live in this home? (required) Do you own your property? (required) YesNo What are you requesting? (required) If someone other than the homeowner/renter prepares this application, or helps the homeowner/renter fill it out, please complete the following: Name of Preparer: Relationship to applicant: Address: Phone: ____________________________ Race and Ethnicity Data (optional) Race and ethnicity information provided by the applicant for services from Heightened Independence and Progress (hipcil) is used for reporting purposes only. Providing this information is optional. Our compiling of such data is expected to benefit the delivery of affiliated services. Information provided (or waiving the option to report this information) will have absolutely no influence on your eligibility for services provided by hipcil. Check all categories that apply. HispanicWhiteAsianBlack or African AmericanNative American or Alaska NativeNative Hawaiian or Other Pacific IslandOther If Other: Please specify: Please check ✓ off one: (required) The above information has been freely and accurately reported, to the best of my knowledge.I choose to exercise my option not to report the requested information ____________________________ Financial Information hipcil uses the following low-income guidelines set by the Bergen County Department of Human Services: Your income for 2023 (100%-200% Federal Poverty Level) - Single ($1,133 - $2,265) - Married ($1,526 - $3,052). Above income, may submit a letter with disability-related expenses and hip with take it into consideration for funding assistance. Please provide financial information below: (required) Income Sources Your income (monthly) Total household income (annually) Employment $ $ Social Security $ $ SSI $ $ Pension $ $ Retirement $ $ VA $ $ Rental $ $ Total monthly income: $ $ Please submit copy of the following document(s). Applications submitted without these document(s) will not be considered, as well as an incomplete application. Proof of income (submit one only) for all residents in your home: • a copy of your (and/or their) W2 or benefit/retirement statement(s) OR • a copy of your (and/or their) last year’s Federal tax return (1040) OR • a copy of your (and/or their) SSI Statement • Doctor’s letter stating your disability and the modification you need done at your current home. • Copy of you identification • Two (2) written estimates from different vendors detailing the home modification and cost of project. • ***Renters are required to provide written permission from the owner of the property and send along with this application Acceptable file types (pdf|txt|doc|docx|jpg|png) Please review before submitting. ____________________________ Independent Living Plan Centers for Independent Living are required to have all consumers either complete and sign an Independent Living Plan on Section 1 or sign if you prefer to waive that option on Section 2 but not both. hip will provide all services to consumers regardless of their choice. Application will not be accepted if this page is not signed, which will delay your funding request. Section 1: Goal To achieve optimal independence and safety at my home. Plan: Make services available to me through hip’s Modification Access Project funding program by submitting all required documents. Projected Date of Completion: ASAP I was responsible for developing my own plan, and I understand that I may change my plan at any time Signature: Date: OR Section 2: Waiver In signing this Independent Living Plan Waiver, I have chosen not to establish goals in writing. I have been informed and understand that I will receive all necessary services from hip regardless of this decision. I further understand that I have the right, at any time I choose, to develop an Independent Living Plan. Signature: Date: * If I am dissatisfied with the services provided to me by Heightened Independence and Progress (hipcil), I can contact the Client Assistance Program (CAP) at 1-800-922-7233 or 609-292-9742 Voice/TDD. The New Jersey Client Assistance Program (CAP) is a federally funded program which advocates for and protects the rights of individuals with disabilities who are seeking or receiving rehabilitation services. *** ____________________________ hipcil - 2024-11 Δ
