Please read this completely before filling out the form.

Prevent Blindness Georgia administers various second party vision care assistance programs. Those organizations have set eligibility requirements which must be strictly adhered to in order to ensure that individuals are truly in need of the benefits from the programs.  

Please note that vouchers are not always available in every county.  Prevent Blindness Georgia may offer vision exams and access to glasses at our community-based vision clinics for certain counties.    

Please note that due to the charitable nature of this program, we assist those that do not have access to vision care at all. If you have a co-pay or a spend down that is required with your vision coverage, you may be ineligible for this program.  

 If you do not have vision care coverage, please complete this application so that we may determine which of the programs you (or your child) may be qualified for. Please read this application in its entirety. Please attach copies of all requested documents so as not to delay processing. Originals cannot be returned.

You will be notified of your eligibility via email or telephone within 4 weeks of receipt of your application.  

You will need:

TWO (2)  proofs of income – they are REQUIRED. Applications WILL NOT be processed without TWO (2) proofs of income. Proof of income or a NOTARIZED document may come from you or someone that may provide financial assistance to you, explaining their assistance. It may also come from an organization (on their letterhead) that is referring you if you have no income. Please note that all applications sent WITHOUT appropriate income verification will not be processed.

Proof of income includes: 

• Last year’s W2
• Last 2 months of bank statements = 1 proof of income
• 2 current paycheck stubs = 1 proof of income
• Social Security Administration Award Letter.
• Unemployment Claim/Wage Inquiry statement
• ANY information regarding financial circumstances, including monthly amounts received on ANY other sources of income (ex: TANF, pension, retirement, child support, food stamps, part time employment, etc.)

If you are having any issues with the form, please email [email protected] or [email protected]

Form Below:

VO Voucher & Clinic Application

Prevent Blindness Georgia administers various second party vision care assistance programs. This form is for individuals who do not have access to vision care at all due to not having vision insurance.

Services needed(Required)

Eye Exam & glasses

Glasses only (please include copy of current prescription)

Surgical (please indicate type of surgery)

Please select which best reflects your needs

Date of Last Exam(Required)

Name

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Phone(Required)

Alternative Phone Number

Email Address(Required)

Number of people in your household (including yourself)(Required)

Please select which type of insurance you have:

Medicaid

Medicare

State Coverage

Vision Coverage through employer

Supplemental Coverage (i.e. AARP, Humana, etc.)

Veteran's Benefits

None

Other

What is the TOTAL yearly family income(Required)

please include ALL household income, spouse's income, dependent income, etc.

Proof of Income

Max. file size: 10 MB.

Proof of Income

Max. file size: 10 MB.

Electronic Signature(Required)

By typing your name here, you are attesting that the above information is true to the best of your knowledge.

Date

MM slash DD slash YYYY