Transit Applications

2. First Name*
3. Last Name*
5. Date of Birth:*
6. Phone Number:*
7. Alternative Phone Number:
9. Reply email addres;*
   Enter NONE if you do not want to be contacted by email
11. Address Line 1*
13. Address 2
15. City*
16. State*
17. Zip*
19. Do you own an automobile?*

    1. Yes
    2. No
20. Are you capable of driving your vehicle?*

    1. Yes
    2. No
21. Do you have friends or relatives who are willing to transport you?*

    1. Yes
    2. No
22. Can you ride the "Sumter Shuttle"?*

    1. Yes
    2. No
24. Are you currently receiving Medicaid benefits?*

    1. Yes
    2. No
25. Do you have extenuating circumstances that prevent you from purchasing transportation?*

    1. Yes
    2. No
26. If yes, please explain:
28. Do you have any special needs that prevent you from driving or walking?

    Check all that apply.

    1. Wheelchair
    2. Walker
    3. Cane
    4. Oxygen

    1. Service Animal
    2. Personal Care Attendant
    3. Other
29. If you selected Other, please list the special need that prevent you from driving or walking here:
31. Please mark the category which your household income falls between:*

    1. $0 - $5,000
    2. $5,000-$10,000
    3. $10,000 - $15,000
    4. $15,000 - $20,000
    5. $20,000 - $25,000
    6. $25,000 - $30,000
    7. $30,000 - $35,000
    8. $35,000 - $40,000
    9. $40,000 - $45,000
    10. Over $45,000
33. Emergency Contact Name:*
34. Emergency Contact Phone Number:*
38. Verification Documents
40. Upload Medical Verification by a licensed medical professional based solely upon the applicant having an actual or cognitive limitation:
    Verification must state the following:
    applicant's name
    the disability
    Whether the disability is permanent or temporary
    If temporary, for what expected duration
    License Information and Contact Information for Medical Professional
    Medical Professional's signature.
41. Upload Income Verification:
    Examples include: Copy of Tax Return, Pay Stub, or W-2.
43. Upload Official Documentation verifying your Age (Copy of Florida Driver's License, Florida ID Card, Birth Certificate, etc)*
47. I understand that the purpose of this evaluation form is to determine my eligibility for paratransit service. I understand that the information about my disabiity contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibiltiy. I hereby authorize my medical representative to release any and all information regarding my medical condition to Sumter County Transit. I understand that providing false or misleading information could result in my eligibility being revoked. I agree to notify Sumter County Transit within 10 days if there is any change in circumstances or I no longer need to use paratransit services.
    
    By submitting this application you agree that the following definition applies to your circumstances: "Transportation disadvantaged" means those persons who because of physical or mental disability, income status, or age are unable to transport themselves or to purchase transportation and are, therefore, dependent upon others to obtain access to health care, employment, education, shopping, social activities, or other life-sustaining activities, or children who are handicapped or high-risk or at-risk as defined in Florida Statutes 411.202.*

    1. I agree.
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field