Half Fare Application Form – Fill Out and Use This PDF

Half Fare Supplemental Application Form

Please return this with your half fare application. Please print.

Name _____________________________________________________________________

TO BE COMPLETED BY A PHYSICIAN OR AGENCY REPRESENTATIVE

The following classifications are not intended to be an exhaustive list, but those disabilities that will most likely result in limiting one’s ability to use public transportation.

The individual has any condition requiring the use of crutches, wheelchair, walker, leg or foot braces, or other such devices in order to be mobile.

The individual has a missing limb or critical part thereof; use of prosthetic devices.

The individual is blind or deaf. Legal blindness automatically qualifies. Legal blindness is one that has a visual acuity of 20/200 or less in the best corrected eye or a visual field of 20A or less in the best corrected eye.

The individual has a musculo-skeletal condition that impairs motor skills to a severe extent, such as muscular dystrophy.

The individual has a mental disability or psychological disorder which substantially limits one or more major life activities such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning or working.

The individual has a temporary disability affecting mobility (lasting at least three months but no more than 12 months) which can be expected to last until

(date) _______________________

Other transportation disability. Please describe:

_____________________________________________________________________

_____________________________________________________________________

PLEASE NOTE: The physician or agency statement on this application must be completed and signed by a qualified physician or agency. IndyGo reserves the right to require any

applicant to provide additional information if needed to clarify or verify a disability. This additional research may take additional time, preventing same day ID issuing.

Updated Nov. 2009

APPLICANT’S STATEMENT

I believe that based on the Half Fare Eligibility Statement (defined by 49CFR.609.), I am qualified to participate in IndyGo’s reduced fare program. I understand that a physician or agency statement describing my disability and how it affects my mobility must be part of the application. I also understand that, if accepted, I will be issued only one reduced fare identification card at a cost of $2.00 I hereby authorize my physician or agency representative to release as necessary medical information to the IndyGo Transportation System regarding my condition.

Signature of Applicant _______________________________________

Today’s Date _____________

IndyGo Indianapolis Public Transportation Corporation

IndyGo Customer Service Retail Center 34 N. Delaware Street

Indianapolis, IN 46204 317.635.3344

PHYSICIAN'S OR AGENCY’S STATEMENT (Please print)

Physician or Agency representative name

________________________________________________

Agency or Medical practice name

______________________________________________________

Address

___________________________________________________________________________

Phone

___________________________

Date

___________________________

Please describe medical condition(s) of applicant:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Updated Nov. 2009

I hereby certify in accordance with federal regulation 49CFR.609.3, ____________________

(Applicant’s Name) in my opinion, qualifies for an IndyGo reduced fare identification card, because his/her disability requires special assistance, facilities, planning or design in order to ride IndyGo buses as effectively as persons who are not so affected.

I declare under the penalty of perjury that the statements on this application are true and correct to the best of my knowledge and belief.

Physician’s or Agent’s signature _____________________________________

Date _____________

In order to receive your photo ID Card; return this form with your application, in person, to the IndyGo Customer Service Center, 34 N. Delaware Street. For information call 635-3344. This program is subject to change by IndyGo. Public notice will be provided regarding any future changes. IndyGo will determine the eligibility of passengers for the half-fare program based upon information provided.

All information provided for half-fare certification process will be confidential and will not be provided to other agencies.

Unless a temporary pass is issued, your half-fare pass will be issued for a three year time period. At the end of the three-year period you will need to renew your application to remain eligible for half fare.

Half Fare Eligibility Statement:

Persons whose disability results in limited ability to use public transportation as defined by Federal Transit Authority (FTA) federal regulation 49CFR.609.3 which provides that disabled persons means those 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.

All certified and registered Open Door riders may show their current Open Door ID on any IndyGo Fixed Route and ride for free.

NOTE: Half Fare ID cards are valid for three years. After ID card expires, please resubmit application and supplemental application for recertification.

Updated Nov. 2009