•  / /
    Pick a Date
  • Do you Qualify?

    If you do not answer "Yes" to any of the qualifying questions below, then you may be ineligible for our program. If you have any questions or concerns about these qualifying questions, please contact us at 800-606-5099.
  • If you clicked no and do not live in Iowa, then you may not be qualified for the program. If you have any questions or concerns about this qualifying question, please contact us at 800-606-5099.

  • If you clicked no, then you may not be qualified for the program. If the applicant is under five years old, please contact us at 800-606-5099.

  • If you clicked no, then you may not be qualified for the program. If you have any questions or concerns about this qualifying question, please contact us at 800-606-5099.

  • If you clicked no, then you may not be qualified for the program. If you have any questions or concerns about this qualifying question, please contact us at 800-606-5099.

  • Annual Total Family Income

    • 1 person - $56,000
    • 2 persons - $65,000
    • 3 persons - $74,000
    • 4 persons - $83,000

    (add $9,000 for each additional person)

  • Equipment Needed

    You can choose one wireless device, but applicants may also select up to two accessories, if desired. Scroll down to see options.
  • You may only choose one of the two ringers - Loud/Flashing Ringer OR Tactile Ringer. Please unselect one of them above.

  • Terms & Conditions

  • I am applying for a wireless device with the TAI program and agree to do the following:

    • Select one wireless telecommunication device.
    • I agree to use the TAI Voucher to get my wireless device through a Wireless Dealer and pay the difference in price (approximately 1%) to purchase the equipment.
    • I agree to set up my wireless device including turning it on, setting up an account with an email address, and reviewing the Terms and Conditions.
    • I agree to use the Apps on the device to make calls on the equipment.
    • I agree to notify TAI within thirty (30) days of any changes in my Iowa address, phone number or email.
    • I agree to keep my wireless device in its protective case and understand that removal of the device from the protective case may void the warranty.
    • I agree to answer all Survey Questions sent to me, whether by mail or email, from TAI about my experience in using the wireless device and to provide feedback so that they may gather information.
  • Professional Signature Required

    If you have not applied to TAI, then you will need a professional signature to verify your hearing loss or your speech difficulty. Please enter your professional's information below, and follow the instructions on the next page on how to get verified.

    You must receive a signature by your doctor, audiologist, voc rehab counselor, state or federal agency representative, or any other licensed professional in the field of hearing or speech.

    The professional should be YOUR "personal" professional, such as your family doctor, a regular audiologist, a sign langauge interpreter you know. Someone that you have an established relationship with.

    Their signature verifies you have a need for specialized telecommunications  equipment to assist communication over the telephone.

  • It is recommended that after you submit this application you reach out to your professional to let them know they will be receiving an email from Telecommunications Access Iowa requiring their verification and signature.

  • Your Signature Required

    By my signature below, I certify that all of the above information is true. By signing this application form, I agree to participate in any follow up survey in order to assure quality customer service and satisfactory use of my equipment. I understand that I am only allowed to receive one item or package of items per family household every five years. I become the owner of the items I receive and am responsible for the maintenance and warranty. I must use the voucher at an authorized dealer by the deadline listed on the form. I agree to pay any remaining cost that is not covered by the Telecommunications Access Iowa Voucher Program.

  • Clear
  •  / /
    Pick a Date
  • Clear
  •  - -
    Pick a Date
  • Should be Empty: