Ddot Fares Form – Fill Out and Use This PDF

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WHO IS ELIGIBLE FOR THE REDUCED FARES PASS CARD?

Applicants who meet one or more of the following eligibility categories are approved for the pass card:

Senior Citizens – Individuals who are age 65 or older are automatically approved;

Legally Blind Persons – Individuals who are documented as “legally blind,” as evidenced by a valid state identification card, are automatically approved;

Medicare Cardholders – Individuals who have been issued a Medicare Card, under Titles II or XVIII of the Social Security Act (49 USC 401 et seq., 1395 et seq.), are automatically approved;

Mobility Disabled Persons – Defined as Individuals who by reason of illness, injury, age, congenital malfunction or other permanent or temporary incapacity or disability, including those who are non- ambulatory wheelchair bound and those with semi-ambulatory capabilities, are unable without special facilities or special planning or design to utilize mass transportation facilities and services as effectively as persons who are not so affected. Individuals who claim eligibility under this category must undergo DDOT’s certification process to receive approval for a pass card.

WHAT ARE THE ELIGIBILITY GUIDELINES FOR MOBILITY DISABLED PERSONS?

Individuals with any incapacity or disability that results in an inability to perform one or more of the following functions, without major difficulty, and who require special planning or design to utilize mass transportation services as effectively as individuals who are not so affected, are eligible as Mobility Disabled Persons:

Negotiating a flight of stairs or escalator

Boarding or alighting from a standard bus or train

Standing in a moving bus or train

Exclusions – All those whose sole incapacity or disability is one of the following:

Any physical, mental or psychological disability or incapacity of less than (30) days.

Pregnancy

Obesity

Impairment due to drugs or alcohol

Controlled epilepsy

HOW TO APPLY FOR A REDUCED FARES PASS CARD?

Applicants must complete Page 3 of the attached application in its entirety; and if certifying as Mobility Disabled, Page 4 as well. Detached and returned the portion labeled “DDOT’s Copy,” along with the supporting documents described on Page 3 for the applicant’s selected eligibility category. Enclose all required documents and mail to DDOT- REDUCED FARES, 1301 E. Warren Ave – 111, Detroit, MI, 48207. Only mailed and complete applications are accepted and processed. All processing fees are non- refundable.

WHAT IS THE CERTIFICATION PROCESS FOR THE REDUCED FARES PASS CARD?

DDOT approves all applicants who automatically qualify for the Reduced Fares pass card. For applicants seeking certification under the Mobility Disabled Persons category, DDOT considers the medical professional’s written diagnosis, before making the final decision on whether an applicant meets the stated requirements. Applicants who are determined “Eligible” are mailed instructions for obtaining and using the Reduced Fares pass card. Applicants who are determined “Ineligible” receive mailed notifications of the reason(s) for the ineligible decision.

**APPLICANT’S COPY **

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**RETURN THIS HALF TO DDOT **

PRINT ONLY IN BLUE OR RED INK ● USE ORIGINAL FORM ● NO PHOTOCOPIES

REDUCED FARES ELIGIBILITY CATEGORIES

Please review the eligibility guidelines listed on Page 2, before selecting from below the eligibility category that best describes you or your disability. Follow the instructions provided for your selected eligibility category to determine the items (supporting documents) to complete and submit along with your application.

I am eligible for the Reduced Fares pass card because…

ELIGIBILITY CATEGORY

INSTRUCTIONS AND SUPPORTING DOCUMENTS

APPLICANT INFORMATION

Valid ID #:			Gender:	□ Male	□ Female
Name:
	First	Middle	Last
Address:
	Street	City	State	Zip
Telephone #: (	)		Date of Birth:
				(mm/dd/yyyy)

Applicant Acknowledgement and Release of Information

I understand that if any of the statements made on this application are false or inaccurate, I may lose the privileges granted under the Reduced Fares program and may be subject to appropriate legal prosecution. I hereby authorize the medical professional completing this application to release any information necessary to complete this certification to DDOT. I understand that this information is confidential and shall not be released without my approval or a court order. I further understand that DDOT shall have the right and opportunity to contact the professional completing this form to obtain additional information about my disability and eligibility for the Reduced Fares program.

Applicant Signature:

Date:

**DDOT’S HALF**

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**RETURN THIS HALF TO DDOT **

PROFESSIONAL CERTIFICATION OF DISABILITY

The applicant is requesting certification as a “Mobility Disabled Person” and the issuance of a Reduced Fares pass card to access the bus at a reduced rate. Per the Federal Transit Administration (FTA), eligible riders are defined as:

“Individuals who by reason of illness, injury, age, congenital malfunction or other permanent or temporary incapacity or disability, including those who are non-ambulatory wheelchair bound and those with semi-ambulatory capabilities, are unable without special facilities or special planning or design to utilize mass transportation facilities and services as effectively as persons who are not so affected.

By completing the following steps, you are confirming that the applicant’s disability prevents him/her from accessing regular bus services as effectively as persons without such a disability and that the stated condition requires special planning or design for the applicant to navigate the bus system. If this is correct, please proceed as follows:

TWO-STEP PROCESS: (Must Complete Both Steps for Certification Consideration)

STEP 1: Application Certification: Complete the section below with the applicant’s name, the specific diagnosis (disability), anticipated term of the condition, and your professional certification.

STEP 2: Letter of Diagnosis: Prepare a letter on your professional letterhead to include your specified diagnosis and detail how it causes a physical impairment of coordination, strength, or endurance that hinders the applicant’s ability to utilize mass transportation. Specify the “special planning or design” that is required to accommodate the applicant’s needs. Complete the letter by signing and entering your professional title and valid State of Michigan license number beneath your signature.

**Please note that while your recommendation(s) will be considered during the certification process, it will not be the sole determinate in DDOT’s decision to certify the applicant.

CERTIFICATION OF APPLICATION

I certify that ________________________________________ meets the eligibility requirements defined for Mobility

(Name of Applicant)

Disabled. The applicant is diagnosed with ___________________________________________________________,

which prevents him/her from performing one or more of the functions listed on Page 2 without major difficulty. See my attached Letter of Diagnosis for additional information. It is my opinion that this disability is: (Check One)

[		]	Temporary	[	]	Semi-Permanent	[	] Permanent
			(Expected to last ___________ months)			(Expected to improve)		(Not likely to improve)
			PROFESSIONAL CERTIFICATION
				*PLEASE PRINT LEGIBLY*
	Professional Name:
			First			Last		Title
	Agency / Office Name:
	Address:
			Street		City		State	Zip
	Michigan
	License		#:	Telephone: (		)	Fax: (	)

Professional Certification:

I understand that if any of the statements made on this application, or in the attached document, are false or inaccurate, DDOT shall preclude me from certifying future applicants. I further understand that if involved in such activities, I will be subject to criminal prosecution in accordance with applicable laws of the State of Michigan.

Professional Signature:

Date:

**DDOT’S HALF**

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