Division for Rehabilitation Services
Office for Deaf and Hard of Hearing Services
Application for
Specialized Telecommunications
Assistance Program (STAP)
DARS3906 Instructions
Purpose
This form is used to apply for a specialized device that provides you (the applicant) with access to a
telephone network.
Detailed Instructions
Print clearly. Illegible or incomplete information may be returned for clarification. The documents used
as proof of residency must include the name of the applicant, parent, or legal guardian signing the
application and must match the home address that appears on the application.
Step 1—Provide applicant’s information
The applicant is the person who needs the device. Supply all of the information requested on the
applicant, including the applicant’s current physical address. A post office box is not acceptable in
place of a physical address.
The mailing address may include a post office box. Vouchers and follow-up letters may be mailed to a
family member or guardian.
Your signature must be original. If you use an “X” for your signature, your signature must be
witnessed, and the witness must also sign the application and enter a date for the signature.
Step 2—Provide proof of Texas residency
To show proof of residency, include a copy of your Texas driver’s license, Medicaid ID, or other
document listed on the application. The document you use must include the name of the applicant,
parent, or legal guardian signing the application. The address on it must match the home address that
appears on the application. The document must be current and must be dated within three months of
the date that DARS receives the application.
Step 3—Meet the disability requirements
You must meet the minimum disability requirements for the devices for which you are applying. The
requirements are indicated on the form to the right of each device listed, and they are defined at the
end of these instructions.
Step 4—Provide a professional certification of your disability
The certifier must explain the applicant’s disabilities and describe in detail the severity as it relates to
the applicant’s ability to access a telephone network.
Additional Information
The application must be complete and must contain the certifier’s original signature. A photocopied,
facsimile, or stamped signature is not acceptable. If your application is incomplete, you will receive a
letter requesting additional information. You may not certify your own application.
DARS3906INST (09/15) A+
Page 1 of 3
Change of Disability
If you have received a device through STAP within the past five years and are applying for a different
device, the certifier must explain why the previous device you received no longer provides you with
adequate access to a telephone network.
Acronyms and Definitions
Definitions, as They Relate to Telephone Access
A person described as having one or more of the following disabilities must have the limitations
described below that impair or prevent access to a telephone network.
Blind—Vision loss of 20/200 or less (or field angle vision of less than 20 degrees) in the better,
unaided eye.
Cognitively impaired—A physical or mental condition that substantially limits a person’s ability to
dial a series of numbers or interpret information to the extent necessary to use a standard telephone.
Deaf—Unaided severe-to-profound hearing loss resulting in the inability to benefit from telephone
amplification.
Hard of hearing—Hearing loss severe enough to necessitate the use of amplification devices to hear
oral communication over telephone lines.
Lower mobility Impaired—A physical impairment that substantially limits a person’s ability to get to
the telephone because of extreme shortness of breath or because the person’s ability to walk is
limited or nonexistent.
Speech impaired—Inarticulate speech that substantially limits a person’s ability to use a standard
telephone. (Additional documentation is required, if you are requesting an anti-stuttering or a speech
generating device.)
Upper mobility impaired—A physical impairment that substantially limits a person’s ability to grip,
lift, or hold a handset, or dial a telephone.
Visually impaired—Vision loss severe enough to interfere with telephone use even with corrective
lenses.
Weak speech—Inaudible speech that substantially limits a person’s ability to use a standard
telephone.
Instructions Unique to This Application
DHHS does not accept this application by fax or email and does not accept expired applications. (For
the expiration date, see the bottom of page one of the application.)
Send the completed application to:
STAP
P.O. Box 12607
Austin, TX 78711
DARS3906INST (09/15) A+
Page 2 of 3
Note about a Version for Screen Readers
This application is available in a Microsoft Word version that is accessible to screen readers.
Note about Retention
Consumers: You may keep a copy of your application for your records. You have one year from the
date that your application is processed to provide any additional information required. DARS staff can
provide a specific date for you. If you submit the information more than one year after that date, you
must submit a new application.
Providers and contractors: Retain the original version of a completed application according to
federal and state laws, DARS policy, and your contract with DARS. If you have questions, contact
your contract manager.
DARS staff and associates: In accordance with federal and state laws and DARS policy, retain the
original version of an application as explained in the table below. For further guidance, see the DARS
Records Retention Schedule or contact DARS Records Management.
If the application is …
then retain the application …
approved and a voucher is exchanged …
for five years from the exchange date.
approved and a voucher is not exchanged
…
until the end of the fiscal year, plus one
year.
denied …
until the end of the fiscal year, plus three
years.
incomplete …
until the end of the fiscal year, plus one
year.
DARS3906INST (09/15) A+
Page 3 of 3