Durable Medical Equipment Assistance Program Request Form
For any questions, please contact:
Department of Disability
201 North Figueroa Street, Suite 100 Los Angeles, CA 90012
Email: DOD-DME@lacity.org | Phone Number: (213) 202-3491 (voice)
The request form will be reviewed upon completion. Once submitted, a DOD staff member will
contact you within the application will be reviewed and approved within 5-10 business days.
Equipment is subject to approval. If an approval is granted, DOD will contact the Agency to notify
them on next steps. By completing this application, you are self-selecting the item(s) for appropriate
use. If additional information is needed to select an appropriate item, please let us know so that we
may connect you to the appropriate organization for assistance.
****For auditing purposes, submit a complete application for your request to be processed.
Does the prospective DME recipient have income verification available?
Yes No
If yes, please submit any of the following:
1) Pay stub, proof of income, government assistance
2) Email from service provider confirming the prospective recipient's CDBG Income Guidelines (see
page 3 for family size and income).
If the above does not apply please submit an application and a DOD staff member will contact you.
The City of LA shall provide reasonable accommodation for effective communication and participation
upon request. To make a request, please contact Zenay Hayward at
Zenay.Hayward@lacity.org or (213) 462-7508, preferably five working days in advance of your
scheduled event.
Please complete the request form below. * (Asterisk) denotes required fields
SECTION 1 Durable Medical Equipment Recipient
*1. Email Address
*2. Name of Service Agency
*3. Agency Point of Contact
*4. Agency Point of Contact Phone Number
*5. Agency Point of Contact Email Address
*6. Name (First & Last) of the DME Recipient
*7. Why does the recipient need the Durable Medical Equipment? Check one.
No insurance
No doctor
No money to cover
Currently have a claim but it is taking too long
Other.
*8. Address for drop-off location (Where DME will be delivered)
*9. DME Recipient Telephone Number
*10. Gender
*11. Age Range. Check one.
Under 17 46 - 55
18 - 26 56 - 64
27 - 35 65 or above
36 - 45
*12. Is the DME Recipient currently experiencing homelessness? Check one.
Yes No
*13. Council District Served (1 - 15 or Mayor's Office) Choose one.
Mayor's Office Council District 9
Council District 1 Council District 10
Council District 2 Council District 11
Council District 3 Council District 12
Council District 4 Council District 13
Council District 5 Council District 14
Council District 6 Council District 15
Council District 7 County
Council District 8
*14. Disability Type. Choose one.
Acquired brain injury Intellectual or Developmental
Blind / Low Vision Mental Health
Cognitive Physical
Deaf-blind Other Disability Type
Deaf or Hard of Hearing
*15. Type of Durable Medical Equipment Request. Choose one.
Cane Front-Wheel Walker
Crutches Rollator / Walker
Extra Wide Walker / Rollator Wheelchair
Extra Wide Wheelchair Other type of Durable Medical Equipment
*SECTION 2 MUST BE COMPLETED - 2021 Community Development Block Grant (CDBG)
Income Guidelines
The application will be denied if the grant requirement questions below are not filled out.
*For auditing purposes, a provider agency intake form with income determination MUST be
included as an email attachment to be considered.
*16. 2021 CDBG Income Guidelines - Choose one Family Size and its Income.
Family Extremely Very Low-Income Low-Income Above 80% of
Size Low-Income “Low” “Mod” Median Income
1 Person $0 - $24,850 $24,851 - $41,400 $41,401 - $66,250 $66,251 +
2 Person $0 - $28,400 $28,401 - $47,300 $47,301 - $75,700 $75,701 +
3 Person $0 - $31,950 $31,951 - $53,200 $53,201 - $85,150 $85,151 +
4 Person $0 - $35,450 $35,451 - $59,100 $59,101 - $94,600 $94,601 +
5 Person $0 - $38,300 $38,301 - $63,850 $63,851 - $102,200 $102,201 +
6 Person $0 - $41,150 $41,151 - $68,600 $68,601 - $109,750 $109,751 +
7 Person $0 - $44,000 $44,001 - $73,300 $73,301 - $117,350 $117,351 +
8 Person $0 - $46,800 $46,801 - $78,050 $78,051 - $124,900 $124,901 +
*17. Presumed Low - and Moderate-Income Persons
In some cases, a funded program may generally presume that an individual meets the federal
income requirements because the funded activity(ies) exclusively serve a group of persons in
any one or a combination of the following 8 categories. If using this method to certify eligibility, a
client must check the box next to the category(ies) of which they are a member:
“Severely disabled” Adult Persons Living with AIDS
Elderly Persons (62 and older) Illiterate Adults
Battered Spouse Migrant Farm Workers
Abused Children
Homeless Persons
*18. Race (check one of the following 10 categories):
American Indian or Alaska Native Asian Asian AND White
Black or African American Black/African American AND White
Native Hawaiian or Other Pacific Islander American Indian/Alaskan Native AND
White Black/African-American
American Indian or Alaska Native and White Balance / Other
*19. Ethnicity - Check one.
Hispanic / Latino Not Hispanic / Latino
I certify that the information provided on this form is accurate and complete, and that
I am a resident of the City of Los Angeles. I further acknowledge that eligibility for
services funded through the CDBG program is based upon having a qualifying annual family
income level or belonging to a group that is presumed to be low- or moderate- income, and that the
income levels and/or status I have indicated in this self-certification may be subject to further
verification by the agency providing services, the City of Los Angeles and/or the U.S. Department of
Housing and Urban Development (HUD).
I therefore authorize such verification and will provide supporting documents if requested. I
acknowledge providing false information shall be grounds for termination from the program /
services.
*Applicant's Name (First and Last Name). Please Print or Type.
*Applicant's Signature (Signature of a parent or guardian person to receive services as a minor)
*Today's Date
*Applicant's Address
*Agency Staff Name (Please Print or Type
*Today's Date
*Agency Staff Signature (Please Print or Type)
Please submit this completed and signed application to DOD-DME@lacity.org.
The request form will be reviewed upon completion. Once submitted, a DOD staff member will
contact you and the application will be reviewed and approved within 5-10 business days.
