• CILNM believes that
all
people should have
access
to their homes
and
communities.
• If you need an access
ramp,
we’d like to help.
• Your ramp will be
provided
to you at cost
and
will be built by
local
volunteers.
CILNM
Ramp Project Application
The Center For
Independent Living of
Please complete the
Modular Ramp Application Form and return to:
CILNM
2104 6th
Ave. E.
Your
name will be placed on a waiting list just as soon as we receive your
application.
If you have questions,
please call (218) 262-6675
January
2004
Modular
Ramp Application
Name:
_________________________________ Date: ____________________
Date of
Birth: ________________ Age: _______ SS#: ____-____-____
Address:
County:
_______________________Phone: (218) ______________________
Gender:
_____M _____ F Disability: _________________________
_____________________________________
_____________________________________
Are
You:
_____ White (Not Hispanic)
_____ Black (Not Hispanic) _____ Hispanic
_____ American Indian or
Alaskan Native _____ Asian or Pacific Islander
Household
Composition:
Please indicate all
persons living in your home.
Name Date of Birth
Relation
___________________________
________________________ _____________________
___________________________
________________________ _____________________
___________________________
________________________ _____________________
___________________________
________________________ _____________________
___________________________
________________________ _____________________
____________
For the past year, what
was your total family income before taxes for all members of your
household? Please check
the appropriate response across from your family size.
All waiver services,
insurance and other second party payors
must must
pay invoice in full upon receipt.
CILNM believes that all
people should have access to their homes and communities.
Based upon this belief
we have developed a sliding fee scale for private parties in need.
The sliding fee scale is
not available for organizations.
Family Size Family
Income
1
Member _____ $ 8,980 or Less _____ $ 8,980 - $ 11,674 _____$ 11,675 or more
2
Members _____ $ 12,120 or Less _____ $ 12,120 - $ 15,756 _____$ 15,757 or more
3
Members _____ $ 15,260 or Less _____ $ 15,260 - $ 19,838 _____$ 19,839 or more
4
Members _____ $ 18,400 or Less _____ $ 18,400 - $ 23,920 _____$ 23,921 or more
5
Members _____ $ 21,540 or Less _____ $ 21,540 - $ 28,002 _____$ 28,003 or more
6
Members _____ $ 24,680 or Less _____ $ 24,680 - $ 32,084 _____$ 32,085 or more
7
Members _____ $ 27,820 or Less _____ $ 27,820 - $ 36,166 _____$ 36,166 or more
8
Members _____ $ 30,960 or Less _____ $ 30,960 - $ 40,248 _____$ 40,249 or more
Why Do You Need A Ramp?
__________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Comments or
Exceptional Situation: ________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do You Need Assistance
With Other Housing Needs? Please Explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do Not
Fill in Shaded Area - Lead Carpenter will explain and fill in amounts
Number and Size of
Modules:
____________ 5’ Starter
Modules at $210 ea $ ______________________
____________ 5’ Modules
at $360 ea $ ______________________
____________ 5’ x 5’
Modules at $450 ea $ ______________________
____________ 5’ x 8’
Modules at $675 ea $ ______________________
____________ 10’ Modules
at $600 ea $ ______________________
____________ Other: $
______________________
Total Ramp Cost
Installed: $ ______________________
____________________________________
_____________________________________
Lead Carpenters
Signature Ramp Renters Signature
Sliding fee scale
monthly rental charge is as follows:
Category
#1 $2 per module Category #2 $ 5 per module Category #3 $ 10 per module
There
may be additional schlorships available for some
consumers. If you cannot
make
the monthly payment please call the Center For Independent Living of
to
explain your situation.
This is
a rent to own program, once the ramp is paid in full, the contractee
will own the ramp;
however,
if the ramp is removed prior to this, the contractee
has no rights to said ramp.
Ramp
Rental Cost
Initial
One Time Charge (First Month’s Rent Plus $ 50 Deposit): $ ______________
Montly Rental Charge Based Upon
Income $
______________
Date
Ramp Was Completed: _________________________________________________
Date of
Inspections: __________________________________________________________
Rental
Agreement
1. I understand that
this ramp will be available to me for up to six months. If there is and
ongoing need for this
ramp, I agree to renew this agreement, purchase the ramp, or
arrange to return the
ramp.
2. I am responsible for
the ramp. I will make sure that it is not damaged or stolen. If it is,
I will report it to the
Center for Independent Living of
I will also report any
ramp repair or maintenance need to CILNM. I understand that I
may not stain or paint
the ramp until I own it.
3. I understand the ramp
that I receive must be returned if:
· I move to another
home.
· There is no longer a
need for the ramp.
· I purchase another
ramp that better serves my needs.
· I become delinquent in
my rental payment of more than 60 days.
4. I understand that I
cannot sell, give away, or loan this ramp to anyone else.
5. I understand that if
I decide to purchase this ramp, 1 through 4 do not apply to me, and
I will assume all repair
and maintenance costs.
6. I understand that the
modular ramp design complies with the
that their design is
determined to be sound. I also understand that volunteers will be
utilized to build and
set up to make this ramp available to me. I acknowledge that I
have been advised of the
risks involved in using such a temporary means of access,
and agree to use this
ramp under these conditions and only with assistance. I hereby
release by my signature
below, any and all liability by the Center for Independent Living,
project volunteers, or
any other associate of this community goodwill project, for any
injuries incurred while
using this ramp.
___________________________________________
____________________________
Signature Date
___________________________________________
____________________________
Witness Signature Date