APPLICATION PREVIEW

Department of Transportation | City of Gainesville

Community Transportation Coordinator for Alachua County

Transportation Disadvantaged Program

34 SE 13th Road
Gainesville, FL 32601
Phone: (352) 334-2600

Dear Transportation Disadvantaged Program Applicant:

Florida’s Transportation Disadvantaged Program was established with the passage of Chapter 427, Florida Statutes. The purpose of this program is to assist individuals who are unable to transport themselves or to purchase transportation due to a physical or mental disability, income status, or age. RTS, the designated Community Transportation Coordinator for Alachua County, is responsible for determining whether individuals are eligible for TD Program assistance. Effective July 1, 2012 the following new criteria will be used to determine whether you qualify for TD Program services:

Unable to transport themselves: Individual is not sponsored by any agency for their transportation and is unable to use the fixed route bus system due to a physical or mental disability defined by the ADA (Enclosed Medical Verification Form required); or

Unable to purchase transportation: Individual applicant income meets maximum of 150% of the current Federal Poverty Guidelines (Proof of Income required. Examples of Proof of Income: most recent pay stub, most recent Social Security Income letter, most recent VA Income letter, etc).

2026 Poverty Guidelines To Determine TD Income Eligibility

For all states (except Alaska and Hawaii) and for the District of Columbia

Size of Family Unit	150% of Poverty
1	$23,475
2	$31,725
3	$39,975
4	$48,225
5	$56,475
…	…

Unable to obtain transportation: Individual does not have an operational vehicle in the household; or the ability to operate a vehicle; or the ability to find transportation from other sources.

Please complete the enclosed application and return it to RTS. RTS will notify you whether your application has been approved or denied within 15 business days. If you have any questions or need assistance completing the application, please contact our office at (352) 334-2600.

Sincerely,
RTS | Department of Transportation | City of Gainesville

Application for Transportation Disadvantaged Trust Fund Services

RTS is the Community Transportation Coordinator (CTC) for Alachua County. The information contained in this application will only be used by RTS to determine your eligibility for Transportation Disadvantaged Trust Fund (TD) services. TD eligibility is determined by a documented disability that prevents you from using or accessing fixed-route bus services, an income-based test and documentation that you cannot purchase or secure transportation through other means. Income tests are based on Federal Poverty Levels and a tiered system. Guidelines are available upon request. Eligibility for this program must be renewed annually. For those recertifying with a permanent disability, a certification from the Center for Independent Living (CIL) can be used in lieu of a doctor statement.

Please print clearly or type. Complete all fields marked with an asterisk (*) and return the form to RTS.

Applicant Information

Date *

Medicaid #

Social Security #

Last Name *

First Name *

Home Address *

Apt

City *

State *

Zip Code *

Home Phone

Work

TDD

E-mail Address

Date of Birth *

Age

Sex

Male Female

Emergency Contact *

Emergency Contact Phone

Eligibility Questions

1. Do you receive food stamps? *

YESNO

2. Do you receive Medicaid? *

YESNO

3. How many family members are in your household? *

4. What is your annual income? * (Provide pay stubs, tax forms or other documentation to support claim)

5. What is your total family household income? *

6. Do you live in an ACLF: nursing home, retirement home or boarding home? *

YESNO

a. Does the facility have a vehicle? *

YESNO

b. Have you ever been transported by this facility? *

YESNO

7. Do you have relatives or friends residing in the same City or County where you live? *

YESNO

a. Would this person transport you if you asked? *

YESNO

b. Have you been transported before to activities/appts. by friends or family? *

YESNO

c. Do you know someone who would transport you if you paid for gas? *

YESNO

8. Do you own an operable vehicle? *

YESNO

a. Can this vehicle be used to transport you? *

YESNO

If No, please explain:

9. Do you use the fixed route bus system? *

YESNO

How many times per week?

Per month?

10. Have you ever used the fixed route bus system? *

YESNO

11. Would you use the fixed route bus system if you were given a bus pass or ticket? *

YESNO

12. Why did you stop using the fixed route bus system? *

13. Is this condition temporary? *

YESNO

If Yes, expected duration of your disability? ____________________ Weeks

14. How does your disability prevent you from using the fixed route bus system? *

15. Are there any other transportation needs of which we should be aware, including cultural competency? *

YESNO

Please explain:

Vehicle and Mobility Information

The following information will be used to ensure that an appropriate vehicle is used to provide transportation.

1. Do you use any of the following mobility aids? (Check all that apply)

a. Manual Wheelchair

b. Power Wheelchair

c. Power Scooter

d. Cane

e. Crutches

f. Walker

g. Service Animal — What kind?

2. Please answer the following questions:

a. Can you travel without assistance a distance of:

200 ft1/4 Mile3/4 Mile

b. Can you climb a 12-inch step? *

YESNO

(If YES) Do you need assistance? YES NO

c. Can you wait outside without support for ten minutes? *

YESNO

d. Can you give an address and telephone number upon request? *

YESNO

e. Can you recognize a destination or landmark? *

YESNO

f. Can you understand and follow directions? *

YESNO

g. Can you handle unexpected situations or changes in your routine? *

YESNO

h. Can you safely and effectively travel through crowded or complex facilities? *

YESNO

Supporting Documents

Important: You must provide the following supporting documents with your application:

Proof of Income: Most recent pay stub, Social Security statement, VA letter, tax return, or other income documentation
Medical Verification Form: Completed and signed by a licensed medical professional (available as a separate form from RTS)

Applicant Certification

I hereby certify that the information submitted above is true and correct. Purposely providing inaccurate information is a violation of State law and may result in legal action.

Date *

Print Name *

Applicant Signature *

Office Use Only

Process Date

Preparer (Print Name)

Initials

Mail or Bring To:

RTS | Department of Transportation | City of Gainesville
34 SE 13th Road, Gainesville, FL 32601
Phone: (352) 334-2600

Supporting Documents: Please mail or bring the following to RTS with this application:

Proof of Income (most recent pay stub, Social Security statement, VA letter, etc.)
Medical Verification Form (completed and signed by a licensed medical professional)

Need help completing this application? Call RTS at (352) 334-2600.

Applicant Name

Medical Verification

To be completed by a licensed professional

Medical Professional Section

Please complete the section below. The information that you provide must be based solely upon the applicant having an actual physical or cognitive limitation, which prevents the use of the fixed route bus service or to drive a vehicle. The diagnosis of a potentially limiting illness or condition is not sufficient determination for Transportation Disadvantaged program services.

What is the applicant’s disability?

How does the condition functionally prevent the applicant from using regular bus service or drive the household vehicle?

Signature of Medical Professional

Date

Professional License #

State Issued

Print Name

Address

State

Zip Code

City

Phone

Extension

Contact Person

Applicant’s Release

I understand that the purpose of this evaluation form is to determine my eligibility for Transportation Disadvantaged program service. I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I hereby authorize my medical representative to release any and all information regarding my medical condition to RTS. I understand that providing false or misleading information could result in my eligibility status being revoked. I agree to notify RTS within 10 days if there is any change in circumstances or I no longer need to use the Transportation Disadvantaged program services.

Applicant Signature

Date

If applicant is unable to sign this form, he/she may have someone sign on his/her behalf.

Signing for Applicant

Relationship

Date

Return To:

RTS | Department of Transportation | City of Gainesville
34 SE 13th Road, Gainesville, FL 32601
Phone: (352) 334-2600