Mississippi Assistive Technology Fund Grant Application
National Federation of the Blind of Mississippi (NFBMS)
Bridging Access Through Innovation
Submission Instructions
Please complete this application and submit it along with:
•	A current eye report
•	A letter describing your need for the requested assistive technology
Submit via:
Mail:
Linda Lankston
767 Main Street
Louise, MS 39097
Email:
nfb.technology@outlook.com 
Phone (for questions):
(662) 836-6872
Please note: A physical signature on a printed copy is required before funds can be awarded.
SECTION 1: Applicant Information
Full Name	__________________________________________	
Street Address	__________________________________________	
City	_____________________	
State	______	
ZIP Code	___________	
Home Phone	__________________________	
Cell Phone	__________________________	
Work Phone	__________________________	
Email Address	__________________________________________	
Date of Application

	________________	
SECTION 2: Eligibility & Background
1.	How long have you been legally blind or blind?

2.	Have you applied for or received funding for this item through any private or government program?
Yes [ ]  No [ ]
If yes, what is the current status of the request?

3.	Have you or anyone in your household been denied an NFBMS grant in the past two years?
Yes [ ]  No [ ]
If yes, please provide details:

SECTION 3: Technology Request
4.	Briefly describe the specific assistive technology or software you are requesting:

5.	Estimated total cost of the item:
$ ___________
6.	How will you provide the required 20% co-payment and any cost beyond the $500 grant amount?

7.	Will this item be used by more than one legally blind or blind individual in your household?
Yes [ ]  No [ ]
If yes, please explain:

8.	Do you currently have a compatible device (e.g., a computer) to use with this technology?
Yes [ ]  No [ ]
If not, how do you plan to obtain one?

SECTION 4: Training and Impact
9.	How do you plan to learn to use this assistive technology?

10.	Explain how this technology will promote your independence and reduce reliance on sighted assistance:

11.	Explain how this technology will support your participation in your community:

SECTION 5: Terms and Disclaimers (Notice to All Applicants)
By submitting this application, you acknowledge and agree to the following conditions:
•	No Reimbursement: Grants are not awarded for equipment already purchased or for used equipment obtained from private individuals.
•	Medical and Subscription-Based Items Not Covered: The NFBMS does not fund any product classified as medical equipment or any item with residual, ongoing, or subscription-based costs.
•	Excluded Equipment: Grants will not be awarded for general-use computers, printers, monitors, or common software applications.
•	Grant is Not a Loan: All grants are gifts and are not repayable.
•	Funding is Not Guaranteed: Grants are subject to availability, applicant history, and alignment with program goals.
•	Alternative Vendors or Items May Be Recommended: NFBMS may suggest alternatives to maximize impact.
•	Priority May Be Given to Applicants Without Existing Technology.
•	Additional Information May Be Requested: Incomplete applications or failure to respond to requests may lead to denial.
•	Program Termination Clause: The program may be suspended or discontinued by a vote of the Board of Directors at any time.
•	NFBMS Assumes No Responsibility for Purchased Equipment: This includes product warranties, functionality, compatibility, installation, training, or support.
•	Return Policy for Unusable Items: If the awarded item is not helpful or usable, it must be returned within 30 days of receipt. NFBMS will seek a refund (if applicable), or reassign the item, and return your co-payment.
SECTION 6: Certification
I certify that all information provided in this application is true, accurate, and correct to the best of my knowledge. I have read, understood, and agree to comply with all terms and conditions outlined in the Mississippi Assistive Technology Fund Grant Program.
Signature: _____________________________________ Date: ________________
Required Attachments:
•	Current eye report
•	A letter describing your need for the requested assistive technology