Apply Online

• To ensure that your loan will be processed in a timely manner, be sure to complete the application in its entirety and to submit all the required documentation listed below.

  PATF will NOT reimburse for a device you have already purchased.

  You can mail, email, or fax the following items to complete your application. Additional documents may be required.

  The following is required for both applicants and co-applicants:
  1. Your Social Security Number. You must call, mail, or fax PATF with this information.
  2. Two copies of identification; one required to be a Photo ID
     Examples include:
     • Driver’s license with current address (Photo ID)
     • Non-driver’s ID with current address (Photo ID)
     • Passport (Photo ID)
     • Utility bill with current address
     • Medical insurance card
     • Social Security card
  3. Proof of income
     Examples include:
     • Two current paystubs and two most recent W-2s
     • IRS Tax Return for the past two years (if self-employed)
     • Supplemental Security Income (SSI) benefit verification letter
     • Social Security Disability Insurance (SSDI) benefit verification letter
     • Child Support/Alimony: You are not required to disclose income from alimony, child support, or separate maintenance payments unless you are using this as a basis for repayment of your loan.
     Additional documentation may be required.
  4. Official vendor quote for the assistive technology (AT) being purchased
     The quote should include the following:
     • A breakdown of costs
     • Vendor contact information
     • If you are purchasing an adapted vehicle, the quote must include: VIN, year, make, mileage, and type of accessible modifications.
  5. The entire and completed application.

  *IMPORTANT: If you have a Representative Payee and the Representative Payee is a family member, that person must be a co-applicant on the loan. By signing as a co-applicant, the rep-payee agrees that he/she is responsible for making the loan payments as he/she would make any payment on behalf of the beneficiary. If the applicant is no longer able to repay the loan the co-applicant would be responsible for paying the remainder of the loan balance.

  The application and supporting documents can be mailed, emailed, or faxed. The application itself can also be completed online by clicking the button below. If you have questions please contact PATF at 484-674-0506 or email patf@patf.us Fax: 484-674-0510 PATF's mailing address: 1004 West 9th Ave., King of Prussia, PA 19406

• SECTION A - PRIVACY STATEMENT AND NOTICE

  Your privacy is important to us, and maintaining your trust and confidence is one of our highest priorities. We respect your right to keep your personal information confidential and understand your desire to avoid unwanted solicitations.

  We are happy to provide this privacy policy notice, and we hope you will take a few minutes to read it. You will have a better understanding of what we do with the information you provide us and how we strive to keep it private and secure.

  This notice explains how we collect, handle, and disclose personal information about you.

  Information We Collect

  We collect non-public personal information about you from the following sources:

  • Information we receive from you on applications and other forms;
  • Information about your transactions with us or others; and,
  • Information we receive from a consumer credit reporting agency (i.e., credit bureaus).

  Information We May Disclose

  We do not disclose non-public personal information about our applicants or borrowers or former applicants or borrowers to anyone, except to our partner banks, the credit bureaus and as required by law.

  Confidentiality and Security of Non-Public Personal Information

  Confidentiality and security of your non-public personal information is of paramount importance to us. We maintain physical, electronic, and procedural safeguards in compliance with all applicable laws and regulations to guard your non-public personal information from unauthorized access, alteration, and destruction. We restrict access to your non-public personal information to those employees and other parties who must use the information to provide services to you.

• Privacy Statement Consent*
  By checking this box and entering my name and initials in the field below, I hereby certify that I am the Applicant and accept that entering the information in the fields below represents my acceptance of the terms of this agreement. This "digital signature" shall be as binding as a physical signature on a paper application for all intents and purposes.
• Type Your Full Name*
• Enter Your Initials*

• • Telling Your Story

    We may use your “story” (for example, why you needed a loan, what equipment or technology you purchased, and how it impacted your life) to explain and market our program to other borrowers and contributors. However, we will not identify you by name unless you give us permission to do so. If you do not wish to have your story told, please indicate below. It will not affect your loan eligibility.

  • Telling Your Story
    • Yes, you may use my story
    • No, please do not use my story

• SECTION B - Loan Request

  Fields marked with a * are required.

• 
  
  • Check appropriate box:*
    • You are applying for individual credit in your own name and are relying on your own income or assets for repayment of the credit requested.
    • You are applying for joint credit with another person.

Required information for PATF to process your application:

• SECTION C - Applicant Information

  Fields marked with a * are required.

  *General Information

  • First Name:*
  • Last Name:*
  • Middle Name:
  • Date of Birth:*
    MM slash DD slash YYYY
  • Home Phone Number:*
  • Cell Phone Number:
  • Email Address:*
  • Current Street Address*
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
  • How Long at this Address:*
  • County:*
  • Number of People in Your Household (Related & Unrelated):*
  *Citizenship Information

  • What is Your Country of Citizenship?:*
  • 
    
  • Citizenship Status:*
    • U.S. Citizen
    • Permanent Resident of U.S.
    • Other
  Previous Address

  • Previous Address
    (if less than two years)
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Employment History

  • Current Employer:
  • Work Number:
  • Position or Title:
  • Years/Months Employed:
  • Employer's Address:
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
  • Previous Employer
    (if less than two years)
  • Previous Employer's Address
    (if less than two years)
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

• *Nearest Relative

  • Name of Nearest Relative or Other Party Not Living With You:*
  • Telephone Number:*
  • Relationship:*
  • Address*
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

• Section D – Co-Applicant Information (If Applicable)

• This section is not required when applying for individual credit without a co-applicant

• Section D – Co-Applicant Information (If Applicable)

  Fields marked with a * are required.

  *General Information

  • First Name:*
  • Last Name:*
  • Middle Name:
  • Date of Birth:*
    MM slash DD slash YYYY
  • Home Phone Number:*
  • Cell Phone Number:
  • Email Address:*
  • Address*
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
  • County:*
  • How Long at this Address:*
  *Citizenship Information

  • What is Your Country of Citizenship?:*
  • Citizenship Status:*
    • U.S. Citizen
    • Permanent Resident of U.S.
    • Other
  Previous Address

  • Previous Address
    (if less than two years)
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Employment History

  • Current Employer:
  • Work Number:
  • Position or Title:
  • Years/Months Employed:
  • Employer's Address:
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
  • Previous Employer
    (if less than two years)
  • Previous Employer's Address
    (if less than two years)
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

• *Nearest Relative

  • Name of Nearest Relative or Other Party Not Living With You:*
  • Telephone Number:*
  • Relationship:*
  • Address*
    Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Section E – Marital Status

Fields marked with a * are required.

Section F – Income & Expenses

Fields marked with a * are required.

• Gross Income*
• Income Source*
• Income Frequency*
  • Weekly
  • Monthly
  • Yearly
• Do you have a checking account?*
  • Yes
  • No
• Do you have a savings account?*
  • Yes
  • No
• Cash in Banks
• Stock/Bonds:
• Retirement Accounts:

Section G – Assistive Technology and User

Fields marked with a * are required.

Section H – Review and Sign

Fields marked with a * are required.

• Certification

Section I – Certification

Fields marked with a * are required.

• {all_fields}