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Do you qualify?
Qualified Iowans will receive a specialized phone, iPhone, or iPad.
Name
*
First
Last
Phone
*
Email
*
Are you a resident of the state of Iowa?
*
Select
Yes
No
This program is only for qualified state of Iowa residents. It has been determined that you do not qualify for this program. Please contact our office at (800)606-5099 for assistance.
Would access to any of the following equipment make phone calls or video calls easier for you?
*
Select
Wireless Tablet
Smartphone
Amplified Phone
Captioned Phone
Specialized Phone
Text Telephone (TTY)
None of the above
Select your preferred device.
This program is only for qualified state of Iowa residents. It has been determined that you do not qualify for this program. Please contact our office at (800)606-5099 for assistance.
Select the number of persons in your family.
*
Select
1
2
3
4
5
6
7
8
9
10
11
12
Is your gross annual family income less than $56,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $65,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $74,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $83,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $92,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $101,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $110,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $119,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $128,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $137,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $146,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Is your gross annual family income less than $155,000?
*
Select
Yes
No
It has been determined that your family income exceeds the qualifying income for this program. Please contact our office at (800)606-5099 for assistance.
Name
First
Last
Email
Phone
