TAP Application TAP

Application Date:

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Veteran Status:

Region:

Map of Regions

Last Name:

First Name:

Middle Initial:

Date of Birth:

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Qualify Disability:

Pay Coupon Application (Income Information not Required)

Family Size: "Family" means the applicant, his dependents and any person legally required to support the applicant, including a spouse

Family Gross Income:
Monthly Annual
"Gross Income" means the income , total cash receipts before taxes from all sources of the applicant, his dependents, and any person legally required to support the applicant, including a spouse

Documentation Required - VDDHH will contact you to request required documentation

APPLICANT ACKNOWLEDGEMENT AND SIGNATURE I understand and agree that:
All information provided above is accurate. Providing false information may result in denial of my TAP application, and any equipment issued must be returned. If I move before I receive my equipment, I will inform VDDHH of my new address. My personal information may be shared with D/HH Specialists for equipment delivery. VDDHH is not responsible for my telephone or internet bill. I accept responsibility for the equipment, including repairs and maintenance costs. If I do not qualify for equipment at no cost, I have the option of paying the state contracted cost for equipment. I will need to submit documentation/proof of my Virginia Residency, Family Size income, or Veteran status when requested by the TAP Administration.

By checking this box, I agree to the above terms

Signature:

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