How to APPLY for partial van assistance?
Step 1: Contact Superior Van & Mobility to find an accessible vehicle that will work for your family and budget.
Step 2: Be sure you have Enrolled with MDFF.
Step 3: Complete our online AVA application below to request funding assistance from MDFF.  Click here to read the full MDFF Agreement & Waiver.
Step 4: Have Superior Van & Mobility send MDFF the Purchase Order (PO) for the vehicle you’re considering.

AVA - Partial Van Assistance Application

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Release Form*
By clicking this box I certify that I have read and fully understand the MDFF Agreement & Waiver in case I am granted any funding for an accessible vehicle. (The document is in Step 3 above)
Do you live in INDIANA?*
If you are not a resident of Indiana, please do not complete this form. Our organization only serves residents of Indiana.
Is the person with MD enrolled with MDFF?*
Enrollment is required to receive services. If you are not yet enrolled, please do so first here: www.mdff.org/enrollmdff
Name of Enrolled person with MD
This person is the "enrollee".
Name of Primary Contact*
Primary contact will be the person who receives all communications regarding this application and other information as needed. This can be the Enrollee themselves, or someone else such as parent/spouse/caregiver/relative if enrollee is a minor or otherwise unable to receive communications.
Is Enrollee eligible for Vocational Rehab assistance?*
Is Enrollee eligible for VA assistance?*

EMPLOYMENT INFORMATION

Please provide employment information for ALL household members that contribute to the household income.
Are you able to afford routine maintenance costs for a vehicle? (such as oil changes, tires, etc)*

VEHICLE INFORMATION

Please include all details about all vehicles currently used/owned/leased/driven by members living within the Enrollee's household. You can enter N/A if not applicable.
i.e. 2018 Ford Escape
i.e. 202k or 84,200
i.e. $250
i.e. 2018 Ford Escape
i.e. 202k or 84,200
i.e. $250
i.e. 2018 Ford Escape
i.e. 202k or 84,200
i.e. $250
i.e. 2018 Ford Escape
i.e. 202k or 84,200
i.e. $250
Calculated after your down payment, vehicle trade-in value, and loan financing.
Who would be the primary licensed driver(s) of the accessible van? Check all that apply.*
Do you anticipate needing any of the following? Check all that apply.*

DOCUMENTS REQUIRED - Uploads (max 10mb)

Physician office letter or part of a medical document
Max. file size: 10 MB.
Max. file size: 50 MB.
For the existing vehicle that would be transferred to new vehicle.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
By signing below, I certify that the above information is accurate to the best of my/our knowledge and may be shared with appropriate parties as needed. I understand the decision of MDFF’s AVA Committee is final. If requested, I agree to a personal interview with representatives of MDFF.*
Thank You for completing the form. If you have not heard back from an MDFF represenative within 7 business days, please reach out to info@mdff.org to make sure we have your application in process. Thank you.