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Change 335 - Form Dfa-Tr-1 - Transportation Remuneration Incentive Program (Trip) Application/redetermination Form Page 2

9. Complete the following information regarding the disability of you or any member of your household

who is mentally or physically handicapped:

Has this Disability been

verified by a Medical

Statement?

Name

Type of Disability

Date of Disability

*Yes

**No

If disability has been determined by any State or Federal agency such as Social Security, Veteran’s

Administration, Department of Health and Human Resources, Worker’s Compensation, Black Lung,

etc., no additional information is necessary.

** If the disability has not been established, it will be necessary to furnish a doctor’s statement stating

when disability began and the approximate length of the disability. (In order to establish eligibility

for disability, the period of anticipated disability must be for one year or longer.)

10. If you need to have someone else to purchase your transportation tickets, complete the following:

(Do not complete if you are able to purchase your own tickets.)

First and Last Name

Mailing Address

11. Before your application can be processed, you must read and answer the following statements:

Yes

I certify I have read or had read to me all the statements on this form and

that the information is true and complete to the best of my knowledge.

Yes

I agree to let the local Department of Health and Human Resources know

immediately if:

1. I move.

2. There is an increase or decrease in my income.

3. I am no longer disabled or handicapped.

Yes

I understand I may request a review on the decision made on my

application for transportation tickets and I may request a fair hearing

regarding any action to which I do not agree.

Yes

I understand that if I violate any of the applicable regulations, I may be

denied the privilege of acquiring and using transportation tickets in the

future.

Yes

I understand that my case may be selected for a review of eligibility and I

will cooperate fully if my case is selected.

Your signature

Signature of your husband or wife

Signature of Person

Date

who helped you fill out this form

THIS APPLICATION CANNOT BE PROCESSED UNLESS IT IS SIGNED BY YOU, YOUR SPOUSE (IF ANY),

AND THE PERSON WHO ASSISTED YOU.

Change 335 - Form Dfa-Tr-1 - Transportation Remuneration Incentive Program (Trip) Application/redetermination Form Page 2

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