NDBEDPReimbursementRequestForm 3

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NDBEDPReimbursementRequestForm 3 Powered By Docstoc
					3                                                                                                                              Rolka Loube Saltzer Associates                   Form v3 page 1

              National Deaf-Blind Equipment Distribution
             Program (NDBEDP) Reimbursement Request
    The NDBEDP is a program mandated by Section 105 of the Twenty-First Century Communications and Video
Accessibility Act (CVAA) that provides funding of up to $10 million annually for the distribution of communications
equipment to low-income individuals who are deaf-blind. This form is designed exclusively for use by entities certified by
the Federal Communications Commission to receive support for the local distribution of equipment to low-income
individuals who are deaf-blind.
                                     Submit this completed and signed form and supporting documentation to:
                                  Rolka Loube Saltzer Associates, 213 Market Street, 12th Floor, Harrisburg, PA 17101
                                                or email to ndbedp@r-l-s-a.com or fax to 888-811-6920

             1. Entity requesting reimbursement:

             2. Personnel contact name:                                                                  Phone:                                           Ext:
             3.                     Email address:
             4. Period when expenses occurred:                                                              Year:                                               State:
                                     (Note that this request must be submitted within 30 days of the close of the period when the expenses occurred)

Reimbursement is requested for costs associated with:               *(Enter total from separate worksheet)
      5. Individualized assessments of applicant eligibility and communication needs                                                                                                 *
             6. Equipment and related expenses                                                                                                                                       *
                       This includes cost of equipment and software, maintenance, repairs, warranties, returns,
                       refurbishing, upgrading and replacing of equipment distributed to disabled consumers

             7. Installation of equipment and individualized consumer training                                                                                                       *
             8. Costs for / Maintenance of an inventory of equipment
                       (Unassigned equipment that can be loaned to a consumer during periods when their
                       assigned equipment is being repaired, equipment used to assess/train users)

             9. Outreach efforts to inform state residents about NDBEDP                                                                                                              *
          10. Administrative costs related to this program
                       Only up to 15% of the total reimbursable costs for the distribution of equipment and
                       related services is permissable.
          11. Total

I swear under penalty of perjury that I am an officer of the above-named reporting entity and that I have examined all cost data associated with equipment and related services for the
claims submitted herein, and that all such data are true and an accurate statement of the affairs of the above-named certified program.

Typed Authorized Officer's Name                          Authorized Officer Signature                                Date                                 Typed Officer Title
Expenses that are not reimbursable by the NDBEDP
   Expenses incurred or paid prior to the official start date of the program
   Costs that exceed the certified program’s annual funding allocation
   Client travel expenses
   Separately invoiced training of family members, personal attendants, or others who might
     provide support on how to use and maintain the distributed equipment (others may be trained
     on how to use and maintain the equipment if such training occurs at the same time as the
     training for the equipment recipient and there is no additional cost incurred for training
     additional people. The NDBEDP will not reimburse costs incurred for training anyone but the
     equipment recipient.)
   “Training the trainer” expenses
   Telecommunications, broadband or other advanced communications services
   Equipment or devices that facilitate other life functions (e.g. , hearing aids, wheelchairs)
   Teaching braille
   Teaching English or other language skills, such as reading or writing
   Teaching keyboarding skills or basic computer skills
   Training to use equipment that was not distributed by an ndbedp certified program
   Converting equipment user manuals or guides into accessible formats
   Assistive lighting (unrelated to signaling devices to alert user to an incoming call)
   Administrative expenses that exceed 15% of the certified program’s total reimbursable expenses
   Other expenses determined by the fcc and/or the trs fund administrator to be not reimbursable
                                                                                               Form v3 page 2

Individualized assessments of applicant eligibility and communication needs:      Costs during period:
     Verification of applicant eligibility (deaf-blind disability & low-income)
     Communications assessments
     Travel expenses for assessment personnel, support service providers,
       and drivers
     Auxiliary aids and services, such as sign language interpreter services
     Other expenses related to eligibility and communications assessments

    Total hours (during period) involved in assessments
                                                                                          Form v3 page 3

Equipment-related:                                                          Costs during period:
     New customer: Cost of specialized customer premises equipment
     New customer: Cost of off-the-shelf hardware
     New customer: Cost of software applications
     Upgrades to existing equipment and replacement hard/software costs
     Travel expenses associated with upgrades and/or repairs
     Maintenance, repair, refurbishing of equipment, costs related to
       handling broken equipment under warranty
     Accessories, such as switches and clamps, required to enable the
       individual to access the equipment
     Devices to alert individuals that they are receiving a communication
       through the distributed equipment, such as flashing lights
     Equipment shipping expenses
     Partial payment for a piece of NDBEDP equipment, when another
       entity pays remaining balance
     Batteries or upgrades for equipment that was not distributed by the
     Other types of equipment that make telecommunications service,
       Internet access service, and advanced communications accessible
       to individuals who are deaf-blind

     Total hours (during period) associated with maintenance, repair,
     warranty and refurbishing of distributed equipment

     Total hours (during period) spent upgrading distributed equipment

     Describe nature of upgrades performed:
For each piece of equipment distributed, provide the following:
                                            Deaf Blind Person                                                 Person Who Attests to the Disability of the Deaf Blind Person                                                                                         Equipment
                                                                                                                                                                                                                                                                                                                                                             # of days between assessment
                                                                                                                                                                                                                                                                                       Type of Communication Service                                             of need and delivery of
Full Name        Street Address                           Email Address   Phone Number   Full Name   Street Address                             Email Address                 Telephone Number   Date Installed   Name of Item   Serial Number   Brand   Function               Cost        with which it is used      Type of relay service it can access             equipment
                                                                                                 Form v3 page 4

Installation and training:                                                          Costs during period:
           Installation of equipment and / or software
           Labor costs related to providing individualized consumer training
           Travel expenses for assessment personnel, support service providers,
             trainers, interveners and drivers
           Instructional materials in an accessible format that are necessary for
             the use of the distributed equipment
           Auxiliary aids and services
           Other expenses related to installation and training

          Total hours (during period) involved in installation or training
                                                                                Form v3 page 5

State and local outreach and education expenses during period
     Participating in outreach and education events and activities, such as
       conducting workshops at deaf-blind related conferences, hosting
       program exhibit booths, and responding to program inquiries
     Development and production of program information
     Development and maintenance of an accessible program website
       formats for the public or applicants, such as flyers, application
       forms, public service announcements, advertisements & press releases
     In-state travel expenses for outreach personnel, support service
       providers, or drivers, such as expenses for mileage to and from
       outreach events
     Auxiliary aids and services, such as sign language interpreter services,
       to ensure effective communication with individuals who are deaf-blind
     Other expenses related to outreach and education

    Total hours (during period) associated with outreach activities

    Type of outreach efforts taken during this period:
Entity requesting reimbursement   Personnel contact name   Phone Extension   Email Address
Period Year State Verification of Eligibility   Communication Assessments   Travel Expenses
Auxiliary Aids and services   Other eligibility or assessment expenses   Hours spent on assessments
New customer specialized equipment   New customer off the shelf hardware
New customer software   Upgrades & Replacements   Travel Expenses   Installation expenses
Maintenance & repair of warranty items   Accessories   Alert devices   Shipping
Partial payment difference   Batteries Other equipment   Hours for maintenance, repair, etc.
Hours for upgrades   Description of upgrades   Labor cost for Training   Travel expenses
Instructional material costs   Auxiliary aids   Other installation and training expenses
Hours involved in installation and training   Costs for equipment inventory
Outreach and education event costs   Development of program information
Development and maintenance of website, etc.   Travel expenses   Auxiliary aids
Other outreach and ed expenses   Hours associated with outreach   Description of outreach activities
Administrative costs

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