1. State law governing Wyoming Relay requires that financial eligibility standards be applied. The purpose of this form is to determine your ability to participate financially in the cost of needed services, and the extent of your participation
2. The family unit means yourself, spouse, minor children or other family members who are designated as dependents on your most recent federal income tax return
3. If you are not of legal age (18 years), or are of legal age but are not emancipated, your parent/guardian must also sign this form
4. Section A - Monthly Gross Income: Enter the source(s) and monthly gross amount(s) of all income received from all sources by the family unit. A11 items should be listed as monthly amount(s). Disability-related income should be listed in the Monthly Gross Income section. However, it should not he included when calculating the subtotal
5. Section B - Liquid Assets: Enter the source(s) and gross amount(s) of any assets, which are or may be converted into cash. Liquid assets include, but are not limited to: cash, savings, stocks and bonds
6. Section C - Total Resources: Add the subtotal of Monthly Gross Income to the subtotal of Liquid Assets (A + R) to obtain Total Resources
7. Section D - Deduction: This section should be filled out with assistance from the Wyoming Relay Program Consultant. Eligible deductions are limited to your disability-related expenses such as attendant care, medications, and maintenance on assistive devices. Use the table below to calculate your monthly allowance far cost of living expenses.
   
   

   Financial Need Table
   Size of Family Unit	Monthly Income
   1	$1,422.00
   2	$1,919.00
   3	$2,416.00
   4	$2,913.00
   5	$3,410.00
   6	$3,907.00
   7	$4,404.00
   8	$4,902.00

   * For family units with more than 8 members, add $262.00 for each additional member.

8. Return the completed financial application form to Wyoming Relay. The Program Consultant can help you complete any sections with which you had difficulty
9. Carefully read the statements above the signature lines. If you have any question, please contact Lori Cielinski at+1 (800) 452-1408 V/TTY

Download Wyoming Relay Application Form