Webpages included in this Technology and Training Fund are:

• Guidelines for ACBVA Technology and Training Fund
• Customer Intake Application (this page)
• Trainer & Technical Support Provider Application

Intake Application

The ACBVA Technology and Training Fund provides financial assistance to blind and low-vision Virginians for adaptive technology, technology training, and specialized technical support. Generally, funding is capped at $1,000 per individual ($500 maximum for technology and $500 maximum for training or technical support). Exceptions may be considered on a case-by-case basis when a customer demonstrates a significant need and sufficient justification is provided.

How to Submit This Application

When encountering choices denoted by left and right brackets, the customer should place an X between the brackets.

This application is designed to be fully accessible. You may submit it using whichever method works best for you:

• Accessible Web Form (Recommended): Complete the HTML version of this application online. This secure form supports screen readers and allows you to apply a validated digital signature certificate upon completion.

• Email (Digital Submission): Save this document, type your answers directly into the fields, and email it as an attachment to tech-fund@acbva.org

• Mail (Printed Submission): Print the form, fill it out, and mail it to:
Technology and Training Review Committee
415 West Rocky Run Road
Fredericksburg, VA 22406

• By Phone: If you require assistance filling out this application, please call (540) 318-3450 and an ACBVA volunteer will assist you.

Section 1: Customer Information

Full Name:
Street Address: (Must be a Virginia resident)
City, State, Zip Code:
Phone Number:
Email Address:

Section 2: Eligibility & Documentation

To qualify for this fund, customers must meet specific eligibility requirements. Assistance provided through the ACBVA Technology and Training Fund is independent of the Virginia Department for the Blind and Vision Impaired (DBVI) Vocational Rehabilitation (VR) Program and other funding sources. You do not need to be an active VR customer to apply.

1. Vision Status & Residency Documentation
   
2. To protect customer privacy and comply with applicable confidentiality requirements, any medical or personal information submitted will be used solely to verify eligibility for this program and will be handled in accordance with ACBVA’s privacy and record-retention procedures.
   
   [ ] I am blind or have low vision, and I am a resident of Virginia.
   
   Verification Method (Select One):
   
   [ ] Medical Professional Verification: I am attaching/emailing a letter from my current or former ophthalmologist or medical professional, dated within the past two years, that confirms my vision status AND lists my current Virginia home address.
   
   [ ] VR / Service Provider Verification: I am attaching/emailing a letter from my current or former DBVI VR counselor or other blindness-related service provider, dated within the past two years, that confirms my vision status AND lists my current Virginia home address.
   
   [ ] Supplemental Residency Proof: I am attaching/emailing a letter regarding my vision status from one of the professionals above, PLUS a digital copy of documentation such as a utility bill or lease agreement proving my current Virginia residency.
   
   [ ] Direct Verification: My medical professional, DBVI VR Counselor, or other qualified service provider will contact ACBVA directly to verify my vision status and Virginia residency.
   
   Financial Need & Alternative Funding
   
   [ ] I attest that I have a financial need for this adaptive/assistive technology or training. Briefly describe justification (e.g. currently unemployed, receiving benefits such as SNAP, Medicaid, SSI, SSDI, living in affordable housing, etc.): ___________
   
   [ ] I have made efforts to obtain funding from other sources (e.g., DBVI and other funding sources).
   
   [ ] Briefly describe your efforts to obtain funding elsewhere (e.g., “Not eligible for VR services,” “Currently on DBVI waitlist,” “receiving services from DBVI that are not comprehensive enough to meet my training needs,” etc.):_______

Section 3: Request Type

Please select all that apply. (You may request both technology and support/training)
[ ] I am requesting Assistive Technology ($500 maximum unless exception is granted under extenuating circumstances)

Please select the category of technology you need:
[ ] Accessible computing device (Smartphone, tablet, computer, or peripheral)

[ ] Software, application, or subscription (e.g., Screen reader, image to text conversion, AI visual tool)

[ ] Braille or tactile technology (braille displays/embossers)

[ ] Smart home devices such as Alexa, or wearables such as meta glasses and smart watches.

[ ] Adaptive daily living device (e.g., magnifiers, specialty lighting, kitchen aids)

Specify the exact item, make/model, and estimated cost (name a vendor or two where device can be obtained, if known):_____

[ ] I am requesting Technology Training or Tech Support ($500 maximum unless exception is granted under extenuating circumstances)

Please select the type of service you need:
[ ] Training: Remote instruction to learn how to use a new device or software.

[ ] Training: Remote instruction to learn how to use a device or software with greater proficiency.

[ ] Device Set-up: Assistance setting up a device because I cannot do it independently or with family assistance.

[ ] Ad-Hoc Tech Support / Mainstream Liaison: A technician to resolve an immediate technical roadblock, assist with a repair/upgrade, or act as a liaison between myself and mainstream corporate tech support.

Describe the specific training or technical issue you need assistance with: _____

Section 4: Primary Functional Goal

To help us measure the success of this fund, please identify the primary functional goal you hope to achieve with this requested technology or training (e.g., reading mail independently, navigating a transit app, organizing paperwork).
My Primary Goal:______

Note: An ACBVA volunteer will conduct a brief follow-up 30 days after you obtain your technology or complete your training to see if this goal was met.

Section 5: Questions

If questions arise when completing this application, please contact:

Technology and Training Review Committee
Phone: (540) 318-3450
Email: tech-fund@acbva.org
Mailing address:
ACB of Virginia
415 W. Rocky Run Rd.
Fredericksburg, VA 22406

Section 6: Acknowledgements

By signing below, the applicant/customer acknowledges and agrees to the following guidelines for the use of these funds:

[ ] Warranties and Liability: ACBVA provides financial assistance only and does not warrant or guarantee any hardware, software, or services; the customer must resolve disputes directly with the manufacturer, vendor, or contractor.

[ ] Software Maintenance Agreements: The customer is responsible for future SMA renewals, extended warranties, or service plans after the initial ACBVA-funded coverage period.

[ ] Supplementing grant funds: The customer may choose to supplement the grant funds with personal funds if the cost exceeds the maximum allowance.

[ ] Selecting trainer/technician: ACBVA will maintain a database of qualified trainers. When requesting training or tech support, the customer will select the trainer/technician. If the customer chooses someone who is not in the database, that person must be vetted by ACBVA, which may result in a delay in the delivery of services owing to ACBVA’s trainer-qualifications-review process.

[ ] Mode of Service Delivery: Training and tech support will predominantly be provided remotely, unless under extenuating circumstances such as setting up a new device where phone or Zoom contact is insufficient.

[ ] Quality of Service and Dispute Resolution: The customer is responsible for managing the trainer relationship; must address conflicts immediately; and must notify ACBVA of unresolvable issues no later than the conclusion of the second session. The customer’s failure to report issues early will result in forfeiture of reimbursement for contested sessions.

Customer Signature:____
Date: ___
(If submitting via the HTML web form, please use the secure digital signature certificate prompt at the bottom of the page. If emailing, typing your name above serves as a digital signature).