Address: City: State: Zip: City: State: Zip: TiLite Information. Please Fax to the TiLite Customer Service Team at or

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1 Page 1 of 7 DEALER INFORMATION RTS INFORMATION Dealer: RTS: Phone: Account: PO: Ordered By: SHIP TO INFORMATION Address: Name: Ship Via: City: State: Zip: Address: Phone: Fax: City: State: Zip: Phone: Fax: Mark For: TiLite Information Promo Code: Ship Date: Order #: Please Fax to the TiLite Customer Service Team at or TiLite YGS shown with Royal Blue Upholstery and other available options. TiLite YG shown with Purple Upholstery and other available options. FRAME STYLE TiLite YG Series(250 Pound Weight Limit) TiLite YG $3,195 TiLite YGS $3,195 Power Adaptable Frame(Requires Billet Aluminum Front Wheels and 0º Camber. Not available with Titanium Quick Release Axles. Camber Tube available in silver anodize only.) $300 Reinforced Frame $300 FRAME FINISHES High Gloss Paint YGFF8 Super Wet Black YGFF9 Sunburst Yellow YGFF10 TiLite Red YGFF11 Military Green YGFF12 Orange Crush YGFF13 Hot Pink Metallic Paint YGFF14 Ocean Blue Metallic YGFF15 Tangerine Metallic YGFF16 Salsa Red Metallic Pearlescent Paint YGFF17 Midnight Blue Pearl YGFF18 White Pearl Matte Paint YGFF19 Black Lava YGFF20 Deep Blue Ice YGFF21 Scarlet Ice YGFF27 Titanium Grey Candy Paint YGFF22 Ruby Red YGFF23 Azure Blue YGFF24 Root Beer Candy YGFF25 Electric Plum YGFF26 Atomic Green TRANSIT TIE-DOWN OPTION YGTTDO Transit Tie-Down Option - Consists of four factory-installed Transit Tie-Down Brackets. Crash-tested in accordance with ISO with a 220 lb (100kg) crash dummy. $295 THIS SECTION MUST BE READ The TiLite YG and YGS with Transit Tie-Down Option (YGTTD0) was crash-tested in accordance with ISO Frontal Impact Test requirements for wheelchairs with 220-lb (100 kg) crash dummy, which corresponds to a person with a weight of up to 250 pounds (113 kg), utilizing vehicle-anchored pelvic and shoulder belts. The crash-tested chairs were configured as follows: 18 Seat Width, 18 Seat Depth, 70 Front Angle, Flip-Up Footrests, Folding Aluminum Adjustable Height and Angle Backrest (set at 20 and 105 for the YG and 18 and 104 for the YGS), Velcro-Adjustable Back Upholstery, Bolt-On Seat Sling Upholstery, 24 rear wheels, 6 plastic casters with poly tires, and swing-away flip back armrests. While the Transit Tie-Down Option is compatible with, and can be purchased with, additional seat sizes, optional components, and varied configurations, and provides designated securement points, TiLite makes no claim that any other components or configuration have been tested beyond the above-described ISO conforming configuration. Please refer to the TILite Transit Tie-Down Option Owner s Manual Supplement for additional information and warnings. The U.S. Department of Transportation has not approved any tie-down system for transportation of a user while in a wheelchair in a moving vehicle of any type. It is TiLite s position that users of wheelchairs should be transferred into appropriate seating in motor vehicles and use the restraints made available by the auto industry. TiLite does not claim that its Transit Tie-Down Option will prevent injury or death in the event of a motor vehicle accident. THE ULTIMATE RIDE. tilite.com 2701 West Court Street Pasco, Washington Tel Toll-Free Fax Toll-Free Fax THE TITANIUM EXPERTS.

2 FRAME MEASUREMENTS Page 2 of 7 H F B I A D E J C SEAT WIDTH A Measure from outside of seat tube at back post to the outside of the opposite seat tube at back post. TiLite YG and YGS Seat Width grows and/or shrinks up to a total of 3. All upholstery and components needed to grow this chair are included. YGSW Set at (Use 1 increments) SEAT DEPTH B Measure from front of back post to the front edge of seat sling. TiLite YG and YGS Seat Depth grows and/or shrinks up to a total of 4. All upholstery and components needed to grow this chair are included. YGSD Set at (Use 1 increments) FRONT SEAT HEIGHT C Measure from floor to top of seat tube at beginning of bend. Adjustable in 1/2 increments. AVAILABLE FRONT Seat HeightS Front Caster Size Min FSH Max FSH 3 3 Frog Legs 4 4 Frog Legs 5 5 Frog Legs 6 6 Frog Legs YGFSH REAR SEAT HEIGHT D Measure from floor to top of seat tube at back post. Adjustable in 1/2 increments. AVAILABLE REAR Seat HeightS Rear Tire Size Min RSH Max RSH 20 Primo 20 Treaded/Herringbone 22 Pyramid 22 Primo/Kenda 22 Treaded 24 Herringbone Tread 24 Primo/Kenda 24 Treaded YGRSH FRONT ANGLE J Measure from inside of frame front tube to top of bottom frame tube. YGFA1 YG YGFA2 YGS

3 FRAME MEASUREMENTS SEAT TO FOOTREST I/FOOTRESTS Measure from front edge of seat sling to top rear of footrest. Measurement must be at least 2 shorter than Front Seat Height C. Page 3 of 7 If your Front Angle J is 70, 80 or 85, select one Seat to Footrest I length and one Footrest type: Standard Footrests YGFTR5 Flip-up Footrest YGFTR19 1- Piece Angle Adjustable Rigid Footrest (YG Only) YGFTR9 Depth Adjustable Flip-up Footrest $95 YGFTR10 Depth & Angle Adjustable Flip-up Footrest (Available for Seat to Footrest E only.) $235 YGFTR11 Angle Adjustable Flip-up Footrest (Available for Seat to Footrest E only.) $195 $115 K0040 High Mount Footrests (Not available with Luggage Carriers or Neoprene Impact Guards.) YGFTR12 High Mount Flip-up Footrest $165 K0037 YGFTR13 Depth Adjustable High Mount Flip-up Footrest $185 YGFTR15 Angle Adjustable High Mount Flip-up Footrest $285 YGFTR16 Depth & Angle Adjustable High Mount Flip-up Footrest $325 YGFTR20 One-Piece Angle Adjustable Rigid High Mount Footrest (YG Only) $115 If your Front Angle J is 90, select one Seat to Footrest I length and one Footrest type (90 Front Angle H not available with Neoprene Impact Guards.): YGFTR5 Flip-up Footrest YGFTR9 Depth Adjustable Flip-up Footrest $95 YGFTR10 Depth & Angle Adjustable Flip-up Footrest $235 YGHLP1 Heel Loops (Not Available with 13 or narrower Seat Width A, 1-Piece Footrests or High Mount Footrests.) $40 E0951 SEAT BACK TYPE/PUSH HANDLES/SEAT BACK HEIGHT F Measure from top of back post to top of seat tube at rear of frame. SEAT Back TYPE YGSB18 Folding Aluminum Adjustable Height and Angle Seat Back PUSH HANDLES YGSB6 Integrated Push Handles YGSB7 Integrated Fold-Down Push Handles (Requires Tension Adjustable by Straps Back Upholstery.) $100 YGSB17 Stroller Handles $275 SEAT BACK HEIGHT F Push Handles Short Medium Tall Set at: (Use 1/2 increments) None Set at: Integrated Set at: Integrated Fold-Down Set at: Stroller Handle Set at: SEAT BACK ANGLE G Measure angle from front of back post to floor. To approximate the angle from the back post to the seat, subtract 2 degrees from measurement G for every.5 of dump. YGSBA REAR WHEEL SPACING H Measure from outside of seat back post to inside of rear tire.3/4 Rear Wheel Spacing not available with 0 or 2 Camber I. YGRWS CAMBER I YGCBR

4 Page 4 of 7 CHAIR OPTIONS FRONT WHEELS YGFW1 3 x.75 Micro-Caster YGFW2 3 x.75 Light-Up Micro-Caster $65 YGFW14 4 x.75 Plastic Wheel w/poly Tire YGFW3 4 x.75 Light-Up Micro-Caster $65 YGFW19 4 x.75 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire Silver Hub OR Black Hub $125 YGFW20 4 x1 Performance 5 Spoke 2-Piece Billet Aluminum Wheel w/soft Roll Tire Silver Hub OR Black Hub $165 YGFW6 5 x1 Plastic Wheel w/poly Tire YGFW21 5 x1 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire Silver Hub OR Black Hub (Not available with 90º Front Angle L.) $145 YGFW22 5 x1 Performance 5 Spoke 2-Piece Billet Aluminum Wheel w/soft Roll Tire Silver Hub OR Black Hub (Not available with 90º Front Angle L.) $185 YGFW9 6 x1 Plastic Wheel w/poly Tire (Not available on YG with 85º Front Angle J or YGS with 90º Front Angle J.) YGFW11 6 x1 Billet Aluminum Wheel w/poly Tire Silver Hub OR Black Hub (Not available on YG with 85º Front Angle J or YGS with 90º Front Angle J.) $165 YGFW10 6 x1.25 Plastic Wheel w/pneumatic Tire (Not available on YG with 85º Front Angle J or YGS with 90º Front Angle J.) $65 YGFW12 6 x1.25 Billet Aluminum Wheel w/pneumatic Tire Silver Hub OR Black Hub (Not available on YG with 85º Front Angle J or YGS with 90º Front Angle J.) $165 YGFW13 6 x Piece Billet Aluminum Wheel w/soft Roll Tire (Not available on YG with 85º Front Angle J or YGS with 90º Front Angle J.) $195 YGFRG1 Frog Legs Suspension Forks (Available in Black anodize only.) $395 E1015 YGCPL1 Caster Pin Locks $225 K0073 YGFW0 Omit Front Wheels (Must choose Wheel Size above) -$20 REAR WHEELS YGRW14 TiLite SHADOW TM (Not available with Titanium Quick Release Axles.) 20 (451) 22 (501) 24 (540) YGRW12 TiLite DASH (Not available with Titanium Quick Release Axles.) $ (451) YGRW5 24 (540) TiLite Wheel w/high Flange Hub (Not available with Titanium Quick Release Axles.) $250 YGRW13 Golz TWIN-STAR Exchange (Not available with Titanium Quick Release Axles.) $ (540) YGRW7 Spinergy SPOX Black Red Yellow Blue White $ (501) - Std. Hub 24 (540) - Std. Hub YGRW8 Spinergy LX Black Red Yellow Blue White Go Green Bright Orange Flamingo Pink (Please allow an additional 2-3 weeks delivery on Go Green, Bright Orange and Flamingo Pink.) $ (501) - Std. Hub 24 (540) - Std. Hub YGRW11 Skyway Mags (Not available with Short Tabs, Titanium Quick Release Axles, Quad Release Axles or Spoke Guards.) $50 YGRW0 Omit Rear Wheels (Must choose Wheel Size above and Tire Type below.) -$50 AXLES YGAXL1 Stainless Quick Release YGAXL2 Titanium Quick Release (Not available with TWIN-STAR Exchange, DASH, SHADOW, Skyway Mags, or Power Adaptable Frame.) $195 YGAXL3 Quad Release $95 PNEUMATIC REAR TIRES YGRTR1 Treaded YGRTR2 Airless Inserts $80 E2213 YGRTR4 Primo YGRTR16 20 Kenda Grey High Pressure (110psi) $95 YGRTR6 24 Grey Knobby (Requires TiLite Wheel with High Flange Hub.) $95 YGRTR5 24 Kenda High Pressure (110psi) Grey Red Blue $85 YGRTR8 24 Schwalbe Marathon Plus Evolution $110 YGRTR9 24 Schwalbe SpeedRun $125 SOLID REAR TIRES YGRTR10 20 (451) Street Tread $65 YGRTR11 22 (501) Pyramid $75 YGRTR13 24 (540) HerringboneTread $90 YGRTR15 24 (540) Treaded $90

5 Page 5 of 7 CHAIR OPTIONS HANDRIMS Handrims by OUT-FRONT YGRIM1 Aluminum Silver Anodized Titanium YGRIM12 Satin Finish $400 YGRIM13 Polished Finish $550 The Natural-Fit (Original, Larger Profile) (Not available with 22 Skyway Mags.) YGRIM14 Standard Grip $295 YGRIM15 Super Grip $340 YGRIM16 Without Thumb Grip $270 The Natural-Fit LT (Reduced Weight, Smaller Profile) (Not available with 22 Skyway Mags.) YGRIM17 Standard Grip $325 YGRIM18 Super Grip $370 YGRIM19 Without Thumb Grip $300 YGRIM10 The Surge (All-In-One Oval with Gription Strip, Larger Profile) (Not available with Skyway Mags.) $315 YGRIM11 The Surge LT (All-In-One Oval with Gription Strip, Smaller Profile) (Not available with Skyway Mags.) $340 YGRIM20 Q-Grip (Exclusive High-Friction, Anti-Slip Coating) (Not available with 22 or 26 Rear Wheels or Skyway Mags.) $295 Additional Handrims YGRIM5 Plastic Coated Black $95 YGRIM9 Spinergy FlexRim (Available only on 24 Spinergy LX Rear Wheels. Please allow an additional 2-3 weeks delivery.) $495 YGRIM6 Projections - 8 Vertical Projections $240 YGRIM0 Omit Handrims -$15 Tab Length YGRIM7 Long Tabs YGRIM8 Short Tabs $15 WHEEL LOCKS YGWLK7 Compact Composite Push to Lock (Available with.75 to 1.5 Rear Wheel Spacing J only) YGWLK8 Compact Composite Pull to Lock (Available with.75 to 1.5 Rear Wheel Spacing J only) YGWLK10 Extension Handles for Compact Composite Push/Pull to Lock YGWLK2 Composite Scissor Lock (Not Available on YGS.) $125 YGWLK5 Black Aluminum Scissor Lock (Not Available on YGS.) $135 $75 E0961 YGWLK3 Uni-Lock Set At: Push OR Pull $135 YGWLK4 Extension Handles for Uni-Lock $75 E0961 UPHOLSTERY COLORS YGUPC1 Black YGUPC2 Ti Red Royal Blue Navy Blue Hunter Green Purple Digital Camo $50 BACK UPHOLSTERY YGBUP2 Velcro Adjustable YGBUP3 Tension Adjustable by Straps $150 YGBUP0 Omit Back Upholstery SEAT UPHOLSTERY YGSUP1 Tension Adjustable Bolt On YGSUP0 Omit Seat Upholstery SEAT CUSHIONS YGCSH1 Foam Cushion $95 YGCSH2 StimuLITE Sport (2 Black 13 x15 to 18 x 18 ) (Please allow an additional 2-3 weeks delivery.) $495 E2603 YGCSH3 Corbee (2 Black 10 x 10 to 16 x 16 )(Please allow an additional 2-3 weeks delivery.) $495 E2603 YGCSH4 ROHO Low Profile Quadtro Select(Please allow an additional 2-3 weeks delivery.) $525 E2624 YGCSH5 ROHO Custom (Please allow an additional 2-3 weeks delivery.) $625 E2609 YGCSH6 VARILITE Evolution $495 E2622 YGCSH7 VARILITE Zoid $495 E2622 Varilite Seat Cushion Availability Chart Seat Depth B Seat Width A VARILITE Evolution VARILITE Zoid , 15, 17 14, 17 8, 12, 14 14, 15, 17 17

6 Page 6 of 7 CHAIR OPTIONS SIDE GUARDS YGSDG1 Cloth $45 Aluminum YGSDG2 Rigid Removable Small OR Std $175 YGSDG3 Quad Removable w/hole Small OR Std $185 YGSDG4 Fold Down Rigid Small OR Std $295 Carbon Fiber YGSDG7 Rigid Removable Small OR Std $270 YGSDG8 Quad Removable w/hole Small OR Std $280 YGSDG9 Fold Down Rigid Small OR Std $400 Available on Aluminum and Carbon Fiber Non-Fendered Side Guards YGSDG13 Side Guards Custom Cut to Profile of Rear Wheels (Not available with Cloth.) $275 ARMRESTS YGARM4 Swing Away - Flip Back Tubular $275 E0973 Covered in Black Ultrasuede $75 SEAT BELTS YGBLT1 Velcro Adjustable, Black Nylon Webbing YGBLT2 Bodypoint 2 Push-Button Buckle (Auto-Style.) YGBLT4 Bodypoint 1 Wide Push-Button Buckle Padded (Auto-Style.) (Not available with 19 or 20 Rear Seat Widths A.) YGBLT5 Bodypoint 1.5 Wide Push-Button Buckle Padded (Auto-Style.) (Not available with 19 or 20 Rear Seat Widths A.) YGBLT6 Bodypoint 1.5 Wide Rehab Latch Buckle Padded (Airline-Style.) (Not available with 19 or 20 Rear Seat Widths A.) YGBLT7 Bodypoint 1.5 Wide Plastic Side Release Padded (Not available with 19 or 20 Rear Seat Widths A.) CALF STRAP YGCLF1 Buckle Adjustable, Black Nylon Webbing YGCLF2 Velcro Adjustable Xtra Small (Recommended for Seat Widths) Small (Recommended for Seat Widths) Medium (Recommended for Seat Widths) YGCLF3 Bodypoint Padded Velcro Adjustable Small (Recommended for Seat Widths) Medium (Recommended for Seat Widths) Large (Recommended for Seat Widths) $45 E0978 $85 E0978 $155 E0978 $155 E0978 $155 E0978 $120 E0978 $25 K0038 $35 K0038 $75 K0038 BACK PACK YGBCK1 Small - Black Nylon $50 YGBCK2 Large - Black Nylon $65 SEAT POUCH YGPCH1 Small - Black Nylon $40 YGPCH2 Large - Black Nylon $45 SPOKE GUARDS YGGRD1 Clear with TiMotion Logo (Not available with Skyway Mags or 20 Rear Wheels.) ANTI-TIPS YGTIP1 Rear Aluminum - Black YGTIP2 User Friendly Rear Flip-up $115 K0065 $135 E0971 $245 E0971 ACCESSORIES YGUEST1 Upper Extremity Support Tray 12 to 14 OR 13 to 15 Seat Widths A (Requires Armrests.) $250 E0950 YGLUG1 Luggage Carriers $125 YGMPCT1 Neoprene Impact Guards $75 YGCH1 Crutch Holder $65 E2207 YGTS1 TiLite T-Shirt Small Medium Large X-Large XX-Large $20 YGHS1 TiLite 9 Piece SAE Round Handle Folding Hex Key Set $20

7 DESIGNS UNLIMITED Page 7 of 7 TiLite s YG/YGS offers hundreds of different frame combinations! But sometimes even that s not enough. If you would like to customize your TiLite, check out the Designs Unlimited Studio at There you will find drawings and pricing for hundreds of creative solutions to customers customization requests. We call these D.U. s. If you don t find the D.U. you re looking for, contact the TiLite Customer Service Team at or customerservice@ tilite.com and we ll design a D.U. just for you. Designs Unlimited customization may add an additional 2 to 3 weeks to the ship time of your chair. GENERAL TiLite manufactures a wide variety of wheelchairs to meet the varied needs of wheelchair users. The final selection of a particular model, its options and accessories, and its measurements rests solely with the wheelchair user and advising healthcare professional. TiLite wheelchairs must be fitted by a qualified healthcare professional. HCPCS Codes are for reference purposes only. Actual coding and coverage varies by payer. Proper HCPCS coding is not a guarantee of payment. Please verify the appropriate payer s coverage policy. Get the latest order forms at tilite.com Prices, standard features, options and accessories are subject to change without notice. All rights reserved. Trademarks are identified by symbols and. TiLite, the TiLite logo, Ti, the Ti logo, The Titanium Experts, TiShaft and The Ultimate Ride are registered trademarks of TiSport, LLC. Adobe, Acrobat, Acrobat Professional and Reader are registered trademarks of Adobe Systems Inc. Bodypoint is a registered trademark of Bodypoint Inc. Frog Legs is a registered trademark of Frog Legs, Inc. Kenda is a registered trademark of Kenda Rubber Industrial Co Ltd. Ride Designs and Corbac are registered trademark of Aspen Seating, LLC. ROHO, Low Profile and Quadtro Select are registered trademarks of ROHO Inc. Schwalbe is a registered trademark of Ralf Bohle GmbH. Supracor, Stimulite and Corbee are registered trademarks of Supracor, Inc. The Natural-Fit is a registered trademark of Three Rivers Holdings, LLC. Varilite is a registered trademark of Cascade Designs, Inc. NOTES If you are using Adobe Acrobat, this order form may be converted into a quote request or into an order by clicking one of the buttons below (this feature is available exclusively to TiLite dealers and distributors). A TiLite Quote or a TiLite Order Confirmation will be sent to you within 24 hours. QUOTE THIS CHAIR ORDER THIS CHAIR