A.C.T.S. - Wheelchair Ramp Application

This is our line application for a Wheelchair Ramp.

Please fill in the application with as much information as possible. Applicants are qualified based on their answers and financial needs. The more information we have the better and quicker we can make an informed decision.

Thank you for your inquiry regarding the acts-tn.org wheelchair ramp building program. The program is designed to assist qualifying individuals with the construction of a wheelchair ramp at minimal or no cost, acts-tn.org is partially funded through a grant from the Tennessee Housing Development Agency, and as such, certain regulations apply if you want to have the lumber paid for under the THDA grant. Before you may be considered for a THDA-funded wheelchair ramp you must provide acts-tn.org with the following information:

1. Documentation to verify the total annual income for the entire household. Complete and sign the Household Member Income form. All household members, regardless of age, must be listed. Relationship to the applicant must be listed. If the member has no income, write zero on the appropriate income line.

Next, enclose additional documentation such as a Social Security benefits letter, bank statement, pay stub, or current tax return for each member listed. Without this information, we cannot add you to our waiting list for THDA-purchased lumber. This is not required if you plan to pay for the lumber yourself. Just note on the application that acts-tn.org should bill you for the cost of lumber.

2. Permission to construct a wheelchair ramp signed by the home’s owner. Please complete and sign the online Permission for Home Modification form. This form must be provided whether you or someone else owns the home.

3. Sign the online Release form.

4. Complete the enclosed Application form. Please provide all the information you have been asked for.

5. Use this checklist to ensure you have all the required paperwork before uploading the documents or mailing them back. Send application materials to:

Actions Completed Through Service-TN

c/o Jimmy C. Barnes

906 Cemetery Rd.

Spring City, TN 37381

Step 1 of 1Summary

Required *

Date Application Submitted

Information About Person Needing Wheelchair Ramp

Full Name

Email Address

Social Security Number

Date of Birth

Are you or your spouse a Veteran of the Armed Forces

Race

Gender

Disability

Disability Narrative

Wheelchair User

Home Church Name

Home Church Address

Site Where Wheelchair Ramp Is Needed

Street Address

Street Address (Line 2)

City

County

State

Zip Code

Phone Number At Location

Directions From Downtown Nashville

Does Applicant (or guardian) Own This Home

Number of People Living in Home

Number of People Living in Home Under 18 Years of Age

Number of People Living in Home Over 18 Years of Age

Full Name

Relationship

Type of Income

Monthly Amount

Yearly Amount

Monthly Total Income

Yearly Income Total

Age

Signature