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iCanConnect California Consumer Application

Part 1: Eligibility and Required Documents

Overview

iCanConnect California is California's National Deaf-Blind Equipment Distribution Program (NDBEDP). The program provides specialized communications equipment, individualized training, installation, and technical support at no cost to eligible Californians who are deafblind to enable access to telecommunications services, Internet access services, and advanced communications
services. 
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The program was created by the Twenty-First Century Communications and Video Accessibility Act of 2010 and is funded and overseen by the Federal Communications Commission (FCC). The FCC certifies one entity in each state to run the program. Communication Service for the Deaf (CSD) is the certified entity for California.

How to Use This Application

The application has three parts. Please note that you can click on any of the “Parts” to jump directly to that section.

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Part 1: Eligibility and Required Documentation
This section explains who qualifies and what documentation you need. You do not need to complete anything in Part 1.

 

Part 2: Application
This is the application form that you complete and submit.

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Part 3: Disability Verification
This section must be completed and signed by a qualified professional who is familiar with your hearing and vision loss. You may detach Part 3 and give it to the professional to complete.​
 

Applications may be completed independently or with assistance from a family member, friend, interpreter, support service provider, rehabilitation professional, or another trusted individual. You may submit your application online, by email, by text message, or by mail.

 

You may be asked to provide documentation of disability and household income.

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If you are unsure whether you qualify, submit an application or contact the program for assistance.

How to Get Help with this Application

If you need help completing this application, or if you would like it in Braille, large print, audio, or another accessible format, contact us. Alternative formats are available on request at no cost.

 

Voice and text message: 323-682-9014 (call or text)

Videophone: 213-870-0165

Email: icanconnectca@csd.org

Website: www.icanconnectca.org

Mail: 2648 International Blvd., Ste. 303 Oakland, CA 94601

Income Eligibility

To be eligible, your total household income must be at or below 400% of the Federal Poverty Guidelines. The table below shows the 2026 amounts. Find the number of people in your household in the first column, then read across to the second column for the income limit.

Number of People in Household
400% of the 2026 Federal Poverty Guidelines
1
$63,840
2
$86,560
3
$109,280
4
$132,000
5
$154,720
6
$177,440
7
$200,160
8
$222,880
For each additional person, add
$22,720

Source: U.S. Department of Health and Human Services. These amounts are updated each year.

There are two ways to show that you meet the income requirement. You only need one. First, you can send proof that you are currently enrolled in a federal program with an income limit that does not exceed 400% of the Federal Poverty Guidelines, such as:

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  • Medicaid (Medi-Cal in California)

  • Low-income home energy assistance

  • Supplemental Security Income (SSI)

  • Federal public housing assistance or Section 8

  • CalFresh, food stamps, or the Supplemental Nutrition Assistance Program (SNAP)

  • Temporary Assistance for Needy Families (TANF) or Welfare to Work (WTW)

  • National School Lunch Program free lunch program

  • Veterans and Survivors Pension Benefit

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Second, you can send proof of your household income. This can be a copy of last year's federal IRS 1040 tax form filed by you and the members of your household, or other evidence of total household income such as a recent Social Security Administration benefit statement or another pension benefit statement. Include a signed statement saying that what you are sending represents your total household income.

How the FCC defines income and household

Income is all income actually received by all members of a household. This includes salary before deductions for taxes, public assistance benefits, social security payments, pensions, unemployment compensation, veteran's benefits, inheritances, alimony, child support payments, worker's compensation benefits, gifts, lottery winnings, and the like. The only exceptions are student financial aid, military housing and cost-of-living allowances, and irregular income from occasional small jobs such as baby-sitting or lawn mowing.

 

A household is any individual or group of individuals who are living together at the same address as one economic unit. A household may include related and unrelated persons. An economic unit consists of all adult individuals contributing to and sharing in the income and expenses of a household. An adult is any person eighteen years or older. If an adult has no or minimal income, and lives with someone who provides financial support to him or her, both people are considered part of the same household. Children under the age of eighteen living with their parents or guardians are considered to be part of the same household as their parents or guardians.

Disability Eligibility

For this program, the term deafblind has the same meaning given by the Helen Keller National Center Act. In general, the individual must have a vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working).

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Specifically, FCC rule 64.6203(c) states that an individual who is deaf-blind is:

(1) Any individual:

(i) Who has a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions;

(ii) Who has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and

(iii) For whom the combination of impairments described in (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.
 

(2) An individual's functional abilities with respect to using telecommunications service, Internet access service, and advanced communications services, including interexchange services and advanced telecommunications and information services in various environments shall be considered when determining whether the individual is deaf-blind under (ii) and (iii) of this section.
 

(3) The definition in this paragraph (c) also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe  hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives.

Who can attest to a person's disability eligibility

A practicing professional who has direct knowledge of the person's vision and hearing loss, such as:

  • Audiologist

  • Specialist in deafblindness

  • Community based service provider

  • Speech pathologist

  • Educator

  • State equipment or assistive technology

  • Hearing professional

  • program

  • Helen Keller National Center (HKNC)

  • Vision professional representative

  • Vocational rehabilitation counselor

  • Medical or health professional

  • School for the deaf or blind

 

Such professionals may also include, in the attestation, information about the individual's functional abilities to use telecommunications, Internet access, and advanced communications services in various settings.

 

Existing documentation that a person is deafblind, such as an individualized education program (IEP) or a statement from a public or private agency such as a Social Security determination letter, may serve as verification of disability.

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Part 3 of this application is the disability verification section that a professional must complete and sign.

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Privacy Notice

The information collected in this application is used solely to determine eligibility, assess communication needs, provide equipment and related services, administer the iCanConnect California program, and satisfy applicable Federal Communications Commission reporting and oversight requirements. Information will be protected and shared only as permitted by applicable law and program requirements.

 

CSD does not sell, lease, or distribute your personal information to third parties unless you give permission or the program is required by law to do so. Physical, electronic, and managerial safeguards are in place to prevent unauthorized access to or disclosure of the information we collect.

FCC Privacy Act Statement

The Federal Communications Commission (FCC) collects personal information about individuals through the National Deaf-Blind Equipment Distribution Program (NDBEDP), a program also known as iCanConnect. The FCC will use this information to administer and manage the NDBEDP. Personal information is provided voluntarily by individuals who request equipment (NDBEDP applicants) and individuals who attest to the disability of NDBEDP applicants. This information is needed to determine whether an applicant is eligible to participate in the NDBEDP. In addition, personal information is provided voluntarily by individuals who file NDBEDP-related complaints with the FCC on behalf of themselves or others. When this information is not provided, it may be impossible to resolve the complaints. Finally, each state's NDBEDP-certified equipment distribution program must submit to the FCC certain personal information that it obtained through its NDBEDP activities. This information is required to maintain each state's certification to participate in this

program.

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The FCC is authorized to collect the personal information that is requested through the NDBEDP under sections 1, 4, and 719 of the Communications Act of 1934, as amended; 47 U.S.C. 151, 154, and 620.

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The FCC may disclose the information collected through the NDBEDP as permitted under the Privacy Act and as described in the FCC's Privacy Act System of Records Notice at 77 FR 2721 (Jan. 19, 2012), FCC/CGB-3, National Deaf-Blind Equipment Distribution Program (NDBEDP).

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This statement is required by the Privacy Act of 1974, Public Law 93-579, 5 U.S.C. 552a(e)(3).

Part 2: Applicant Information

Please complete all fields. If a question does not apply to you, write "N/A" or leave it blank. If you need help, or need this application in another format, contact us at 323-682-9014 (voice or text), 213-870-0165 (videophone), or icanconnectca@csd.org.

Applicant Information Form

Section A. Applicant

Date of birth
Month
Day
Year

If the applicant is under 18 years of age, a parent or legal guardian must sign this application in Section E.

Equipment is shipped to your street address, so this cannot be a post office box.

Permanent resident of California:
Yes
No
Mailing address is the same as the street address above:
Yes
No

Section B. Contact Preferences

Preferred contact method (check all that apply):
Preferred format for letters and program materials (check all that apply):
Language preference (check all that apply):

Alternative contact, in case we cannot reach you (optional)

Section C. Income Eligibility

How you will show that you meet the income requirement (choose one):
I am enrolled in one of the federal programs listed in Part 1, and will send proof
I will send proof of my household income
I need help with this. Please contact me.
If qualifying through a federal program, which one (check all that apply):
Income documentation attached to this application:
Yes, it is attached
No, I will send it separately
No, I need help getting it
If attached, what you are sending (check all that apply):

Section D. Referral Information

How you heard about iCanConnect California (check all that apply):
Self-referral
Yes
No

Section E. Certification and Signature

I certify that all information provided on this application, including information about my disability and income, is true, complete, and accurate to the best of my knowledge. I authorize program representatives to verify the information provided.


I permit information about me to be shared with my state's current and successor program managers and representatives for the administration of the program and for the delivery of equipment and services to me. I also permit information about me to be reported to the Federal Communications Commission for the administration, operation, and oversight of the program. If I move and apply to another state's iCanConnect program, I also permit every state iCanConnect program I have participated in to send my program records to that program.


I authorize iCanConnect California to release my name, address, and contact information to a trainer for the purposes of assessment and training.


If I am accepted into the program, I agree to use program services solely for the purposes intended.


I understand that I may not sell, give, or lend to another person any equipment provided to me by the program. I will care for the equipment.


If I provide any false records or fail to comply with these or other requirements or conditions of the program, program officials may end services to me immediately. If I intentionally violate these or other program requirements or conditions, program officials may take appropriate action as permitted by law.


I certify that I have read, understand, and accept these conditions to participate in iCanConnect (the National Deaf-Blind Equipment Distribution Program).

Applicant Certification

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Signed by the applicant, or by a parent or legal guardian if the applicant is under 18. Typing your full name in the signature space is accepted as your signature.

Date
Month
Day
Year

If someone other than the applicant completed or signed this application

Part 3: Disability Verification

This disability verification section is to be completed by a practicing professional who has direct knowledge of the applicant's vision and hearing loss.

 

You can share the link with them: https://icanconnectca.org/online-application#part3disabilityverification

 

To the Practicing Professional: Please complete and submit this online form. 

Disability Verification Form

Section F: Name and Address of Deafblind Individual

Section G: Attester Information

Section H: Definition of Deafblindness

For this program, the term deafblind has the same meaning given by the Helen Keller National Center Act. In general, the individual must have a certain vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working).


Specifically, the FCC's NDBEDP rule 64.6203(c) states that an individual who is deaf-blind is:

(1) Any individual:

(i) Who has a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions;

(ii) Who has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and

(iii) For whom the combination of impairments described in (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.


(2) An individual's functional abilities with respect to using telecommunications service, Internet access service, and advanced communications services, including interexchange services and advanced telecommunications and information services in various environments shall be considered when determining whether the individual is deaf-blind under (ii) and (iii) of this section.


(3) The definition in this paragraph (c) also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives.

Section I: Attestation

I certify under penalty of perjury that, to the best of my knowledge, this individual is deafblind as defined by the FCC rule stated above.


My attestation is based on the following. Please state how you are familiar with each of the applicant's hearing loss and vision loss, and with the applicant's combination of hearing and vision loss, as defined in the FCC's NDBEDP rule listed directly above.

Section J. Attester Signature

Attester certification:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Typing your full name in the signature space is accepted as your signature.

Section K: Submitting this Application

Submit your application, your income documentation, and Disability Verification form. 
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This application is available in Braille, large print, audio, and accessible electronic formats at no cost. Click here to download an accessible application to complete at your own pace. Otherwise, contact us using any of the methods above.

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What happens next

1. We review your application for completeness and eligibility.

2. We contact you if additional information is needed.

3. We schedule an individualized communications needs assessment.

4. We recommend appropriate communications equipment and related services.

5. We arrange equipment delivery, installation, and individualized training.

6. We provide follow-up technical assistance and support as needed.

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