ADA COMPLEMENTARY PARATRANSIT ELIGIBILITY APPLICATION

APPLICANT INFORMATION
Last Name First Name MI Date of Birth
M D YEAR

Phone Number Cell Home Phone Number Cell Home

email Sex Language

M F
Street Address Apartment # Building #

City State Zip Code Require gate code? Code:

Y N

EMERGENCY CONTACT INFORMATION (optional)

Last Name First Name

Phone Number Cell Home Relationship

NON-APPLICANT COMPLETING THE APPLICATION (If you are completing this application for someone else please provide your
information) *IF CLIENT IS UNABLE TO SIGN, THE SIGNATURE OF THE INDIVIDUAL COMPLETING THE APPLICATION IS REQUIRED BELOW
Last Name First Name

Phone Number Cell Home Relationship

I authorize my health care professional to release any and all information about my disability or health condition and its
affect on my ability to travel on the Fixed Route Bus. I understand that I may revoke this authorization at any time. I
understand that the Mobility Coordinator’s office may contact the health care professional who completed the verification
attached to this application, in order to confirm this information. I understand that all medical information will be kept strictly
confidential. I hereby certify that, to the best of my knowledge, information given in this application is correct. I
understand that intentionally providing false or misleading information may affect my eligibility for ADA complementary
paratransit. I agree to notify the Mobility Coordinator’s office if my condition changes, if I am using a new mobility device, or
if I no longer need to use ADA complimentary paratransit services.
Signature Date

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 TRANSPORTATION DISADVANTAGED ELIGIBILITY APPLICATION
APPLICANT INFORMATION
Last Name First Name MI Date of Birth
M D YEAR

Phone Number Cell Home Phone Number Cell Home

email Sex Language

M F
Street Address Apartment # Building #

City State Zip Code Require gate code? Code:

Y N

EMERGENCY CONTACT INFORMATION (optional)

Last Name First Name

Phone Number Cell Home Relationship

NON-APPLICANT COMPLETING THE APPLICATION (If you are completing this application for someone else please provide your
information) *IF CLIENT IS UNABLE TO SIGN, THE SIGNATURE OF THE INDIVIDUAL COMPLETING THE APPLICATION IS REQUIRED BELOW
Last Name First Name

Phone Number Cell Home Relationship

TD ELIGIBILITY QUESTIONNAIRE - OTHER TRANSPORTATION SOURCES/FUNDING

Are you able to find transportation to appointment or life sustaining activities? Y N`

IF NO: How do you currently get from your point of origin to appointments or life sustaining activities?

How many vehicles are in your household?

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 TRANSPORTATION DISADVANTAGED ELIGIBILITY APPLICATION
TD ELIGIBILITY QUESTIONNAIRE - AGE IF YOU ARE OVER 65 YOU DO NOT
NEED TO ANSWER THE FOLLOWING
What is your age at time of application?
SECTIONS

TD ELIGIBILITY QUESTIONNAIRE - DISABILITY

Do you have an active ADA complimentary paratransit
Do you have a physical or mental disability ? Y N Y N
eligibility decision?

IF YES: To qualify for TD services based on a physical or mental disability the ADA Complimentary Paratransit & TD Eligibility medical
verification form must be completed by your doctor and returned to the Mobility Coordinator’s office

IF YOU HAVE ANSWERED YES TO THIS SECTION YOU DO NOT NEED TO ANSWER
THE FINANCIAL QUESTIONS BELOW.
YOU ONLY NEED TO COMPLETE THE SIGNATURE SECTION

TD ELIGIBILITY QUESTIONNAIRE - FINANCES

How many people are in your household? What is the applicant’s gross annual income?

Gross income must be verified by official documentation. Official documentation includes any of the following:

•1st page of last years tax return •Social Security income verification or proof of income letter (SSI
and SSDI)

•DCF cash benefit/child support letter •Retirement/pension income statement

•Unemployment compensation income verification •Proof of VA disability income

If you claim no income, you must submit proof of Food Stamp eligibility or a signed letter on agency letterhead verifying you have
no income.
APPLICATIONS MISSING PROOF OF INCOME/NO INCOME WILL NOT BE APPROVED FOR TD SERVICES UNTIL INCOME
INFORMATION IS RECIEVED

I authorize my health care professional to release any and all information about my disability or health condition and its
affect on my ability to obtain transportation . I understand that I may revoke this authorization at any time. I understand that
the Mobility Coordinator’s office may contact the health care professional who completed the verification attached to this
application, in order to confirm this information. I understand that all medical information will be kept strictly confidential. I
hereby certify that, to the best of my knowledge, information given in this application is correct. I understand that
intentionally providing false or misleading information may affect my eligibility for TD services. I agree to notify the Mobility
Coordinator’s office if my condition changes, if I am using a new mobility device, or if I no longer need to use TD services.

Signature Date

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 ADA COMPLEMENTARY PARATRANSIT & TD ELIGIBILITY MEDICAL VERIFICATION FORM
Last Name First Name MI Date of Birth
M D YEAR

Medical Professional's Info

Name of Medical Professional Title

Office address Suite #

City State Zip Code License #

Please list the applicant’s disabilities/impairments

Are these permanent? Y N If not, how long is recovery expected to be:

According to your diagnosis and medical opinion can the applicant do any of the following?
Use the fixed-route system
Y N See bus signs, stops, and traffic signs Y N
independently
Understand how to use the bus (fares,
Walk to the bus stop Y N Y N
wayfinding)
Transfer from one bus to another at a
Wait for the bus Y N Y N
transfer point
Board the bus with assistance of a ramp
Y N
or kneeling bus

Does the applicant require any of the following mobility aids?

Powerchair Powered scooter Cane Braces

Wheelchair Walker Crutches Oxygen

In signing, I acknowledge that, to the best of my knowledge, the information in the form is true and correct.
Furthermore, I certify that objecting medical testing/documentation that substantiates the diagnosis is part of the
client’s medical records. I understand that providing false or misleading information could affect the eligibility of the
client and may result in prosecution to the maximum extent allowed by the laws of the State of Florida.
Phone Number

Fax
Signature
Email

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If you are applying for service due to a medically verified physical or cognitive condition, impairment, or
disability this MEDICAL VERIFICATION FORM must be completed and signed by a licensed medical professional.
Acceptable medical professions include:
• Medical Doctor • Audiologist • APRN/PA
• Doctor of Osteopathic Medicine • Ophthalmologist • Occupational/Physical Therapist
• Doctor of Chiropractic • Psychologist • Licensed Clinical Social Worker

For the medical professional:

In order to process this applicant’s request for ADA Complimentary Paratransit or Transportation Disadvantaged
services we require this form to be completed. Only licensed medical professionals having knowledge of the appli-
cant’s functional ability to independently use the fixed-route bus service should complete this form.
Please return the completed MEDICAL VERIFICATION FORM to the customer, mail, fax, or email to the mobility
coordinator at:
Mobility Coordinator
5303 Pinkney Ave
Sarasota, FL 34233

Fax: 941-861-1007

Email: eligibility@scgov.net

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