Home Accessibility Application Process In-Take Form

If you live in our services area, please complete this form to begin the process of applying for assistance with building a ramp or home modification. Once The Ability Center receives the basic information requested below, you will be contacted and asked to complete a formal application

If you have any questions about this form, or the ramp you are requesting, please contact Becky Myers at (419) 885-5733.

Information on other housing resources available at The Ability Center can be found on the Community Living and Information Services page. You must be a resident of Lucas, Ottawa, or Wood county or the City of Toledo to apply for a ramp or accessibility home modification.

Please Provide Your Information

Fields marked with are required.

Name

Address

City

State

Zip Code

County
Lucas Ottawa Wood City of Toledo
Home Phone

Work Phone

Email Address

Applicant's Birthday [Use format mm/dd/yyyy]

Please list the names and ages of everyone in the household:

Name Relationship Age
Name Relationship Age
Name Relationship Age

Disability/Diagnosis
Enter disability/diagnosis here

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