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Transportation Disadvantaged or Rural Eligibility Assessment

  1. Enter NONE if you do not want to be contacted by email
  2. Do you own an automobile?*
  3. Are you capable of driving your vehicle?*
  4. Do you have friends or relatives who are willing to transport you?*
  5. Can you ride the "Sumter Shuttle"?*
  6. Are you currently receiving Medicaid benefits?*
  7. Do you have extenuating circumstances that prevent you from purchasing transportation?*
  8. Do you have any special needs that prevent you from driving or walking?

    Check all that apply.

  9. Please mark the category which your household income falls between:*
  10. Verification Documents
  11. 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.
  12. Examples include: Copy of Tax Return, Pay Stub, or W-2.
  13. 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.*
  14. Leave This Blank:

  15. This field is not part of the form submission.