CILNM believes that all people should have access to independent living
services, where situations prevent people with disabilities to come to
CILNM we will come to them via the Internet. 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. The funds received
into this program from the sliding fee scale will be put back into the
program, which will allow others to participate in the program. Priority
will be given to people in very rural areas with few other services.
CILNM 1101 E. 37th Street,
Mesabi Mall, Suite 25
Hibbing, MN 55746
V/TTY (218) 262-6675 FAX (218) 262-6677
Fields Marked with an * Are Required.
*
Last Name:
*
Email Address:
Date of Birth:
Age:
Street Address:
*
City:
*
Zip:
*
Phone#:
*
Gender:
Male Female *
Disability:
*
Are You: *
White (not Hispanic)
Asian or Pacific Islander
Black (not Hispanic)
Hispanic
American Indian or Alaskan Native
Why do you need this assistive technology?
*
Additional Comments or exceptional situation:
*
Do you need assistance with other disability related needs? Please explain:
*
Household Composition
Please indicate all persons living in your home:
For the past year what was the total family income before taxes for all members of your household? Please check the appropriate response across from your family size.
Household Size *
Category 1
Category 2
Category 3
1 Member
$15,350 or less
$15,351 - $24,550
$24,551 or more
2 Members
$17,500 or less
$17,501 - $28,050
$28,051 or more
3 Members
$19,700 or less
$19,701 - $31,550
$31,551 or more
4 Members
$21,900 or less
$21,901 - $35,050
$35,051 or more
5 Members
$23,650 or less
$23,651 - $37,850
$37,851 or more
6 Members
$25,400 or less
$25,401 - $40,650
$40,651 or more
7 Members
$27,150 or less
$27,151 - $43,450
$43,451 or more
8 Members
$28,900 or less
$28,901 - $46,250
$46,251 or more *
Sliding fee scale monthly rental charge is as follows:
CATEGORY 1 $30 month
CATEGORY 2 $40 month
CATEGORY 3 $50 month
There will be a $50 deposit required on the day your computer is set up for you.
0% (Zero) Interest. You may choose to pay off your computer and/or other technology more quickly if you like.
RENTAL AGREEMENT
I understand that this equipment is made
available to me with public funds. This is a credit program to enable me
to own my own computer. Once the technology is paid in full, I will own
it; however, if the technology is removed prior to this, I have no said
rights to this equipment.
I am responsible for the equipment. I will make
sure that it is not damaged or stolen. I am responsible for it's
maintenance and upkeep. I understand that I may not make alterations to
the hardware until I fully own it.
I understand the technology that I receive must
be returned if I become delinquent in my rental payment of more than 60
days.
I understand that I cannot sell, give away, or
loan this equipment to anyone else until it is completely paid for and
if I do I am still responsible for the debt.
I understand that I will assume all repair and
maintenance costs.
I understand that I may pay off the debt at any
time, or continue the sliding fee scale payment plan until my debt is
paid in full
I understand and agree to utilize the modifications under these conditions. 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 participating in this project.