You must have JavaScript enabled to use this form. Please fill out the simple form below and we'll tell you what programs you qualify for. Is the account holder 62 years or older? Yes No Members in Household --Select One--12345678910 What is the total monthly income before taxes for all household members? This includes income from work, government benefits, and support payments, among others. Does the account holder have a long lasting or life-threatening disability that prevents them from working enough to support themselves and their household? Yes No Does the account holder or a household member use a life support device? Yes No Some examples of eligible life support devices are Aerosol TentsApnea MonitorsBreather Machines (IPPB)Compressors / ConcentratorsDialysis MachinesElectronic Nerve StimulatorsElectrostatic NebulizersHemodialysis MachinesInhalation Pulmonary Pressure DevicesIron LungsMotorized WheelchairsOxygen GeneratorsPressure PadsRespirators Suction MachinesUltrasonic NebulizersIf you use a life support device not listed above, you may still be eligible. Does the account holder or a household member have paralysis, multiple sclerosis, neuromuscular disorder, scleroderma, or a compromised immune system that requires extra heating or cooling for medical reasons? Yes No Leave this field blank
