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Change 335 - Form Dfa-Tr-1 - Transportation Remuneration Incentive Program (Trip) Application/redetermination Form

WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES

Transportation Remuneration Incentive Program (TRIP)

Application/Redetermination Form

Do Not Write in This Space –

For Department Use Only

Case No.:_____________________

o Application

o Redetermination

1. Date of Application/Redetermination

2. Name:

3. Address (Street and Box #):

City, State, Zip:

4. Directions to your home:

5. Telephone Number:

If you do not have a telephone, can you be contacted by calling

a relative or neighbor? Yes

If yes, give their name and telephone number:

Name:

Telephone:

6. Have you ever received TRIP tickets before?

Yes

7. List the following information about yourself and all other persons living in your household:

Full Name

Date of Birth

Social

Relationship

*Income

**Gross

Security

Source

Income

Number

Amount

*Identify Source of Income such as Social Security, Black Lung, Workers’ Compensation, Public

Assistance, Salary, etc.

** If you receive a paycheck, enter your gross pay. This is the amount before any deductions. (Income taxes,

etc.)

8. Eligibility for Extra Ticket Books – Check appropriate blocks:

□ One round trip from my home to nearest city or town costs more than $8 per month.

□ Visiting doctor, clinic, sheltered workshop or hospital costs more than $8 per month. (Doctor’s

statement is needed)

□ Forced use of more expensive type of transportation to visit doctor, clinic, sheltered workshop,

costs more than $8 per month. (Doctor’s statement is needed)

□ Need someone to travel with me or for me because of age, illness or disability. This includes

medical appointments and to pharmacy, etc. (Doctor’s statement is needed)

DFA-TR-1 (New 8/04)

Change 335 - Form Dfa-Tr-1 - Transportation Remuneration Incentive Program (Trip) Application/redetermination Form

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