PERRY COUNTY TRANSIT

Application for Honored Citizen Eligibility

Reduced fare only applies within Perry County

Perry County Transit is offering reduced fare for riders who are Disabled or Age 60 and older. Funding for these fare discounts are subsidized through the Ohio Department of Transportation, which has established specific eligibility requirements.

Obtaining your ride discount is easy and free of charge. Please follow these simple steps allowing up to 5 days for your eligibility of reduced fare to be applied.

To qualify for reduced fare based on your AGE: Complete Sections A & C

Submit this completed application form with proof of your date of birth. Acceptable verification of date of birth would be a copy of your birth certificate, valid driver's license or state identification card (issued by the Ohio Bureau of Motor Vehicles).

To qualify for reduced fare based on DISABILITY/HANDICAP: Complete Sections A, B & C

Submit this completed application form with appropriate verification. Acceptable verification is a Social Security award letter verifying your receipt of disability benefits or a current Medicare card. Call Social Security at 1-800-772-1213 and ask for TPQY printout.

Complete sections A, B & C if you do not have any of the above verifications are you are applying under DISABILITY/HANDICAP.

The Administration of Perry County Transit is solely responsible for approval or rejection of applications for reduced fare eligibility based on program criteria. Appeals may be made to the Perry County Commissioners and the Ohio Department of Transportation. Completed application, verification of Eligibility and requests for assistance in completing this application should be addressed to Perry County Transit, 499 N State St, New Lexington, Ohio 43764. Phone number (740) 342-2810

Section A

Last name

First Name

M.I.

Date of Birth

Address

City, State & Zip Code

Phone

Height

Weight

Gender

Hair

Eyes

Nationality

I am applying for Perry County Transit reduced fare based on

Age (60 or older). Acceptable proof of date of birth must be presented with application. A physical or mental disability. Social Security Award Letter, Medicare Card or Physicians Certificate (B) must be submitted.

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PERRY COUNTY TRANSIT

Section B — Physician's Certification of Disability/Handicap

Specify that the customer qualified with a “physical or mental impairment that substantially limits one of more of the major life activities of an individual” under the Americans with Disability Act.

Certification

Patient's Name

Applicant's disability is

permanent temporary

If temporary, list ending date

Physicians Signature

Physician's Name (printed)

Address

Phone

Date

Accessibility (feel free to call if any other accessibilities are needed)

Section C

This information will only be used to determine eligibility for the reduced fare program for the Elderly and disabled program.

I state that the above statements are correct and true to the best of my knowledge. I understand that false statements on this application represents a violation of the conditions and terms of the program and will result in the denial of the privilege by Perry County Transit.

Applicants signature (If under 18, parent or guardians' signature)

Date

For Official Use Only

Approved By

Date

Number

THANK YOU FOR CHOOSING THE SERVICES OF PERRY COUNTY TRANSIT

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