Ramp Up/Fixin' to Stay Louisiana
Request for Assistance

The goal of Ramp Up/Fixin' to Stay Louisiana is to provide ramps and home modifications to Louisiana citizens with disabilities and impairments and to do so with as little hassle as possible. To do this, we have assembled a working-group of government agencies and other service providers who may be able to provide funding for your project. By completing this worksheet, you are giving us the information we require to try to point you in the right direction for services tailored to your unique needs, and agree to have your request for help sent to potential sources of assistance so that they may review your information and decide whether you qualify for their help.

Each of our partners has different requirements for eligibility, so some of the questions will apply to you while others may not. Take a moment to provide as much of the information as you can. Check 'Yes' only if the question pertains to you, otherwise leave the question blank.

Section 1 : How Can We Help You ?
We’ll ask for your name and other information in just a bit. For now, we want to know how Ramp Up/Fixin’ to Stay Louisiana can help you.

1-1. Do you need a wheelchair ramp to improve access to your home? Yes No
1-2. Do you need any of the following other modifications for access purposes?
Bathroom (tub, shower, or toilet) Yes No
Kitchen (sink, stove, etc.) Yes No
1-3. Are some of your light switches too high for you to reach? Yes No
1-4. Do you need access improvements to interior or exterior door handles? Yes No
1-5. Do you need wider door frames? Yes No
If so, how many?
1-6. Is there anything else you need in or around your home that we have not asked about? If so, please describe below.

1-7. Would these improvements make it easier for you to attend work or school? Yes No
Section 2 : Property To Be Modified
2-1. Physical Address of Property You Wish to Modify:
2-1-a. Street Address
2-1-b. Unit. #
2-1-c. City
2-1-d. State
2-1-e. ZIP Code
2-2. Which parish is the property in?
2-3. Do you own and occupy the home and lot you wish to modify? Yes No
2-3-a. If so, what is the estimated value of your home?
2-4. Do you rent your home? Yes No
2-5. Do you live with relatives? Yes No

Section 3 : Now Tell Us About You
For our purposes, the Applicant is the person (adult or child) who needs the help, and the Co-Applicant could be a spouse or parent helping the Applicant.

3-1. Applicant’s Full Name:
3-2. Co-Applicant’s Full Name:
3-3. Mailing Address:
3-3-a. Street Number
3-3-b. Unit #
3-3-c. City
3-3-d. State
3-3-e. ZIP Code
3-4. Home Phone:
3-5. Work Phone:
3-6. Cell Phone:
3-7. Email Address:
Section 4 : Household Financial Information
Please provide whatever financial information you can. You do not need to be exact at this point, so it is okay if you do not know exact ages or dollar amounts. Just approximate for now.

Household Members: Relation: Married? Sex: Age: Disability? Gross Monthly Income:
Applicant XXXXXXX Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
Yes No M F Yes No
ASSETS: Checking Account $
Savings Account $
Automobile(s) $
Other $
Do you own other real estate? Yes No
If so, what is its value? $

Section 5 : Government Assistance
5-1. Please indicate which of the following benefits you receive:
5-1-a.Louisiana Rehabilitation Services (LRS) Yes No
5-1-b.SSI Benefits Yes No
5-1-c.Social Security Disability Yes No
5-1-d.Social Security Retirement Yes No
5-1-e.Medicaid Yes No
5-1-f.Medicaid Waiver Yes No
5-1-f-1.Elderly & Disabled Yes No
5-1-f-2.Children’s Choice Yes No
5-1-f-3.NOW Yes No
5-1-f-4.Supports Yes No
5-1-g.Traumatic Brain Injury Fund Yes No
5-1-h.VA Disability Benefits Yes No
5-1-i.I’m not sure which benefits I receive Yes No
5-2. If you filed income taxes last year, did you receive an Earned Income Credit? Yes No
5-2-a. If so, how much?
5-3. Are you currently receiving food stamps? Yes No
5-3-a. If so, how much per month?
5-4. Do you receive any benefits not listed above? If so, please describe them below.
Section 6 : Declared Disaster
As you know, many of our citizens were affected by a Declared Disaster. Some programs might be geared specifically to those Louisianians in designated disaster areas. This section lets us know who might be available for this specialized assistance, but does not necessarily disqualify other applicants from taking part in non-Disaster-related programs. This section is only for those affected by a Declared Disaster.

6-1. What was your address before the disaster?
6-1-a. Street Address
6-1-b. Unit. #
6-1-c. City
6-1-d. State
6-1-e. Zip Code
6-2. In what parish did you live?
6-3. What is your FEMA #?:
6-4. Are you currently living in FEMA-provided housing, such as a trailer? Yes No

Section 7 : Acceptance
By completing and electronically submitting this Request for Assistance, you are authorizing us to send your information to potential sources of assistance. If you have any questions, please call and ask for the Ramp Up, Louisiana Administrator at (225) 342-0332.

7-1. Did someone help you fill out this form? Yes No
7-1-a. If so, what is their name?
7-1-b. Would it be okay for us to contact this person?
Yes
No
Only if we are unable to contact you
Only after we contact you
7-1-c. Would you rather that we deal directly with this person? Yes No
7-1-d. What is their phone number?
7-1-e. What is their email address (if they have one)?

7-2. Do you authorize Ramp Up/Fixin’ to Stay Louisiana to contact any government or non-profit agency that might be able to help you? Yes No