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Application for the Authorization of Equipment Repair or Replacement – previous version

Form number: 1091

This form is to be used for applications relating to the September 1, 2016–August 31, 2017 award year.

You need to fill out this form if you have already acquired a device under the Allowance for Special Needs Program and the equipment needs to be repaired or replaced.

This form must be accompanied by a signed quote from the dealer or signed by an authorized person from the technical assistance service.

The cost of the repair or replacement is only reimbursed once in a lifetime.

Only students in adult general education and vocational training programs at the secondary school level or who are enrolled at private unsubsidized educational institutions are eligible to receive reimbursement for the cost of repairs to equipment acquired under the Allowance for Special Needs Program.

Download the form

Digital transmission

After you print the form, fill it out, have your school attendance confirmed by an authorized employee at your educational institution’s student financial aid office, then sign the form and scan it. Use our Online Services to upload the completed form.

Other way to submit your document

Mail

If you are unable to submit this form digitally you can mail it to us. Print the form, fill it out, have your school attendance confirmed by an authorized employee at your educational institution’s student financial aid office, then sign it and mail it to the address shown on the form itself.

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