CALL 'N' RIDE APPLICATION

Call ‘N’ Ride is a transportation assistance program for income eligible residents of Montgomery County, who are age 67 and above, or persons age 16 and above with mental or physical disabilities.

To apply for this program, please complete this confidential application and return it along with all required documentation to the address below:

To apply for this program please complete both pages of this confidential application and return it to the address below:

CALL ‘N’ RIDE
P. O. BOX 8465
GAITHERSBURG, MD. 20898-8465
TELEPHONE: 301-948-5409 FAX: 301-258-0206

THE FOLLOWING QUESTIONS ARE ASKED TO DETERMINE YOUR PROGRAM ELIGIBILITY.

1. RESIDENCY AND AGE:

Please submit proof of Montgomery County residency. Proof of residency can be a copy of a rental agreement, or copy of property tax bill or deed, or a copy of a current Maryland ID card with current address or a copy of a utility bill with your name and address.

Please submit proof of age with the application.

Name		Date of Birth	01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900	Age
Spouse’s Name		Date of Birth	01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900	Age
Street Address		Apt#
City		State		Zip Code
Telephone		How many persons live in your household

Is this a group home, nursing home, etc?  Yes No

2. INCOME:

Please submit proof of income with this application. Proof of income can be a copy of your income tax return, Social Security check, Social Security award letter, pension, annuity statements, SSI, job earnings, bank statement to show interest, dividend payments, IRA distributions. etc.

2A. Do you currently receive SSI (Supplemental Security Income), GPA (General Public Assistance), or Food Stamps?  Yes No

If you answered YES to 2A., please submit a letter of proof from the agency from which you receive assistance. Skip to Question #3. If you answered NO, please complete the following section.

2B. If you do not receive SSI, GPA, or Food Stamps, what is your gross monthly income from all sources?
$ Please send proof.

If you answered YES please submit a disability form, either mental or physical, along with the application. If you do not have a disability form or if you need any other information, please call 301-948-5409.

If answered yes, please explain

3A. If your disability is temporary, how long do you anticipate being disabled?

3B. Do you require the use of  wheelchair  walker crutches ?

4. PLEASE CHECK ONE OF THE FOLLOWING:

The participant will directly order and handle coupons themselves.

The following person will order and handle coupons and should be contacted if there are any questions regarding the participant’s use of the service.

NAME		TELEPHONE
ADDRESS
RELATIONSHIP

5. THE FOLLOWING QUESTIONS PROVIDE STATISTICAL INFORMATION FOR PROGRAM EVALUATION. PLEASE ANSWER THESE QUESTIONS:

5A. Are you able to utilize: Metrobus?   Yes No       Ride-On Bus?   Yes No

5B. Are you aware you can ride free on Ride On and Metrobuses all day everyday?   Yes No

5C. If not, how do these services not meet your needs?

6. HOW MANY TIMES PER MONTH DO YOU REQUIRE TRANSPORTATION?  

6A. Do you currently receive transportation services from any agency or service provider? (i.e. City of Rockville, Jewish Council for Aging, Spanish-Speaking Community of Maryland, Special Transportation, Metro Access, etc.) Yes No

6B. If yes, please specify:

The information provided by me is confidential, and is used only to determine my eligibility to participate in the Call 'N' Ride Program.  I certify that all information contained on this form is true and correct

SIGNATURE __________________________________ DATE __________________