City Of Tucson Transit Reduced Fare Program - Disabled Application Form Page 2

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Disabled Application
1. Personal Information
Please print or type
 Mr.  Mrs.  Ms. ________________________________________________________________________
Last Name
First Name
Middle Initial
Place of residence
 Personal residence
 Long term care facility: ________________________________________________
 Shelter: _____________________________________________________________
 Group home: ________________________________________________________
 Other (Please specify) ________________________________________________
Address: _______________________________________________________________ Apt: ______________
City: __________________________________________ State: ________________ Zip Code: _____________
Phone Number: (
)_________________________ E-mail: ________________________________________
Birthdate: ____ /____ /_______
Month Day
Year
2. Proof of Disability Documentation
To qualify as a disabled individual, the applicant must, by reason of illness, injury, congenital malfunction,
or other disability, be unable to utilize mass transit as effectively as others. Conditions which DO NOT
qualify are: pregnancy, obesity, acute or chronic alcoholism or drug addiction, and contagious diseases
which pose a danger to other passengers.
Please provide one of the following documents as proof of disability to qualify for a disabled ID card.
Complete the appropriate section based on the document you are providing.
 Medicare Card (section A)
 Social Security Disability Insurance (SSDI) award letter (section B)
 D.E.S. Vocational Rehabilitation referral & letter from physician (section C)
 Valid ADA Paratransit Eligibility Card (section D)
 Certification from physician (section E)
A. Medicare Card
 I am a recipient of Medicare. I am submitting my Medicare Card as proof of disability.
B. Social Security Disability Insurance (SSDI) award letter
 I currently receive Social Security Disability Insurance (SSDI) benefits from the United States Social
Security Administration (SSA). I am submitting my SSDI award letter as proof of disability.
C. D.E.S. Vocational Rehabilitation referral
 I am eligible to receive Vocational Rehabilitation services from the Department of Economic Security. I am
submitting my D.E.S. Vocational Rehabilitation referral letter and letter from physician as proof of disability.
D. Valid ADA Paratransit Eligibility Card
 I am eligible for ADA Paratransit services. I am submitting my valid ADA Paratransit Eligibility Card as
proof of disability.
(1 of 2)
rev 3/1/13

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