Division for Rehabilitation Services

Office for Deaf and Hard of Hearing Services

Specialized Telecommunications Assistance Program

Change of Disability
Applicant Information
Applicant name:

Telephone number: ( )	Application number:

Address:

Email address:

Disability Information
1. Provide a detailed description of how the applicant's disability has changed since the applicant exchanged the previous STAP voucher.

2. Identify the cause of the change of disability and state if the applicant's condition is progressive or stable.

Device Information
3. List all devices received by exchanging a STAP voucher within the last 5 years. The list must include the model name, number, and manufacturer of each device.

4. Provide a detailed description of why the applicant can no longer use the devices received by exchanging the previous STAP voucher for telephone access.

5. List all devices for which the applicant is applying in order to achieve basic telephone network access. The list must include the model name, number, and manufacturer of each device.

6. DHHS will not issue a voucher for any device that is functionally similar to a device received using a STAP voucher exchanged within the last 5 years (identified under 3.) unless the previously received device is not compatible with another device in the current request. List any device (identified under 5.) that is functionally similar to any device received using a STAP voucher within the last 5 years (identified under 3.) that is not compatible. Explain why the device is not compatible.

Certifier Information
Printed name of certifier:

Name of business:

Title:

Certification or license number:

Street address:

City:

State:

ZIP code:

Telephone:

( )	Fax:

( )	Email:

Signature of certifier (must be original, not a photocopy, facsimile, or stamp):
X	Date:

Send completed form to:

Office for Deaf and Hard of Hearing Services

PO Box 12607, Austin, Texas 78711

(512) 407-3250 Voice or (512) 407-3251 TTY

http://www.dars.state.tx.us/dhhs/stap.shtml

DARS3926 (09/09) A+	STAP Change of Disability	Page 2 of 2

DARS3926 (09/09) A+	Page 1 of 2

DARS3926, DHHS Change of Disability

DARS

2009-08-27

Mike Moore