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Online Application

Fill in the online form, print it and take to your dealership for their signature prior to submitting for vehicle equipment reimbursement.
Or, you can print out a blank form and provide the required information and dealer signature.

Required documents for reimbursement approval

  • Completed application form
  • Copy of vehicle registration
  • Copy of itemized paid invoice from adaptive equipment company
  • Copy of signed Buyer’s Order or Lease Agreement
  • Original prescription/letter from a licensed medical doctor when required (see item #3)

Vehicle Owner Information

Please follow the claim instructions carefully and be sure that all sections of this form are completed before mailing to Automobility Program Headquarters.

Dealer Information

Total cost of adaptive equipment and installation: $

Description of adaptive equipment installed:

Payment issued to