Application For Riverside Transit Agency Disabled Identification Card

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Application for Riverside Transit Agency Disabled Identification Card
Last Name: _______________________________ First Name: _____________________________
Address: ____________________________________________________ Apt#: __________
City: ______________________________________ State: ______
Zip Code: ___________
Telephone Number: (
) _________-____________
Date of Birth: _____ /______ / _____
Are you eligible for Medi-Cal?
____ Yes ____ No
If yes, what is your Medi-Cal number: __________________________________________
Check the category under which you are applying for a Disabled ID Card. Categories 1-5 require you to present
your identification card to prove your participation of eligibility in the program checked below.
1. ___ Medicare Identification Card (white card with red and blue stripes)
2. ___ Department of Motor Vehicles (DMV) Disabled Person Placard Receipt
3. ___ Braille Institute Identification Card
4. ___ Disabled Veteran Service - Connected Identification Card
5. ___ SSI Disability Award Letter (Social Security Income)
Please check disability type on the reverse page.
If Categories 1-5 do not apply to you, check either 6 or 7 and follow specific instructions.
6. ___ Medical Disability – Give this application to a licensed healthcare professional to complete based on
Eligibility Criteria.
7. ___ Special Education – Enrollment in a Special Education Program for students who are enrolled in an
elementary, junior/middle or senior high school. Give this application to your Special Education teacher to
complete.
I hereby apply for a Riverside Transit Agency Disabled I.D. Card. I agree to abide by the fare policies of the
Riverside Transit Agency. I declare, under penalty of perjury under the laws of the State of California, that the
responses I have given are true.
____________________________________________________ Date: ____/____/____
Applicant’s Signature (Or legal guardian if under 18 years old):
After this application has been completed, come to the Riverside YWCA, 8172 Magnolia Ave., on the second
Tuesday of each month between 9 a.m. and noon to receive your identification card. A photo ID is required.
There will be a cost of $2 for the card. Applications MAY be processed by mail. For more information or if you
have any questions, please call (951) 565-5002 or 511.
APPLICATION CONTINUES >>>>
Effective January 16, 2013

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