Ramp it Up Application Mar 13, 2018 Ramp it Up Application Step 1 of 2 50% Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Primary PhoneOther PhoneDate of Birth Date Format: MM slash DD slash YYYY AgeI. Property information(A) Directions to Home(B) House:OwnRentTax Number:If rental proceed to (B); if mobile home proceed to (C)Address Street Address City State / Province / Region ZIP / Postal Code (C) Rental InformationOwner Name First Last Address Street Address City State / Province / Region ZIP / Postal Code Owner Phone(D) Mobile Home: Own Rent Private Lot Mobile Home Park Park NamePark Manager First Last Park Manager Phone Number II. Mobility Information: Check each that appliesAre you unstable/unsteady entering/exiting your home? Yes No Are you unable to enter/exit your home without assistance? Yes No Has a medical professional recommended that you ALWAYS use a walker outside of your home? Yes No Do you rely on a wheelchair/scooter to travel more than a few steps? Yes No Are you generally confined to a wheelchair/scooter? Yes No Is there more than one mobility-limited person living in your home? Yes No Do you have family/friends nearby who can assist you? Yes No Please describe your disability:III. Household ResourcesProvide a written explanation if there are financial circumstances you wish us to consider when determining income eligibility.Applicant IncomeSocial SecurityDisability IncomeOther IncomePensionEmploymentTotalSpouse/PartnerSocial SecurityDisability IncomeOther IncomePensionEmploymentTotalOtherRelationshipSocial SecurityDisability IncomeOther IncomePensionEmploymentTotalOtherRelationshipSocial SecurityDisability IncomeOther IncomePensionEmploymentTotalNameThis field is for validation purposes and should be left unchanged.
