ACTRP Inquiry
Please note:
this is a rental program and fees will apply.
Consumer's First Name
*
Consumer's Middle Initial
Consumer's Last Name
*
Your first name, if you are inquiring on behalf of the Consumer
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
County of Residence
*
Please Select
Allen
Defiance
Fulton
Hancock
Henry
Lucas
Ottawa
Paulding
Putnam
Sandusky
Seneca
Williams
Wood
Not Listed - Indiana
Not Listed - Michigan
Not Listed - Ohio
Not Listed - Other
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Back
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Specific Needs
When does the Consumer need the ramp by? A lead time of a minimum of ten business days is required.
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the Consumer the homeowner of their residence?
*
Please Select
Yes
No
Is the Consumer in rehab and in need of the ramp for safe discharge?
*
Please Select
Yes
No
Is it possible that the Consumer will need a permanent ramp?
*
Please Select
Yes
No
Additional Notes/Comments
Submit
Should be Empty: