Application Forms

Assisting Oregonians With Physical Disabilities Since 1981

WHEN THE APPLICANT IS A DEPENDENT CHILD
In the instance of a dependent child (a child under the age of 18 living in the household),
all household income (earned income, Social Security, annuities, child support, etc.)
must be listed in the income column of the Income Worksheet.

Application Form

You may choose from whichever of the following formats best suits your needs. The content of each is identical, but the specific formatting of each will result in significantly different printed document length. The approximate printed length of each version appears in parentheses ( ) following the keyboard access code.

Application Form In Adobe PDF Format (7 pages; requires Adobe® Acrobat® Reader, which is available FREE from Adobe. The forms must be printed out to submit. (Be certain to fill out and include the Income Worksheet with the application.)

YOU MAY FILL OUT THE APPLICATION BY HAND--or ask someone else to fill it out for you. It is essential that you (or your guardian/agent) signs the application.

If you would rather not print it, please call us (503.246.4941) and we will mail you an application packet.

REMEMBER:
·        The application must be filled out completely and signed by the applicant or applicant's legal guardian.

·        The Income Worksheet must accompany the application.

·        Medical or other satisfactory verification of disability (letter from Health Care Provider, Social Worker or Case
         Manager) is required.

·        A quote or order information for the service or item for which you are applying must be enclosed.

·        We do not accept electronically transmitted applications.

Applications missing any of the above will be returned.