Hard of Hearing Alarm Application
To participate in this program, you must
Answer all questions, on both the front and back sides of this form
Be a Maryland resident with a hearing impairment
Provide proof of your need (letter from doctor, medical provider, audiologist, professional, etc.) NOT live in an institutional facility (dorm, nursing home, etc.)
Do you have a contact person who you would rather us contact for scheduling and followup requirements?
Information Regarding the Residence
Does the Residence Have Currently Working Smoke Alarms?
Preferred Method of Contact?
Upload Your Proof of Need Here
This program is operated on limited funding and generous donations. We ask those who are capable,
please donate to this needed program to help those less fortunate. These devices retail for approximately $300.00 each.
Any contributions to offset the costs are greatly appreciated. Thank you!
You Can Make contributions by check payable to: FABSCOM – DHH Fund or use our paypal link below.
Information collected is kept confidential and used for follow-up by FABSCOM only.