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Persons with Disabilities (PwD) Project Application

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If you would like to use this service, you may either download the .pdf version of the PwD application and send it along with a copy of one of the documents listed in Part 2 of the application to:

Indiana County Transit Authority
P.O. Box 869
Indiana, PA 15701
Fax: 724-465-1933

Or, you may complete this online application and separately send the required documentation as listed in Part 2 of the application to Indiana County Transit Authority. A .pdf copy of Supplement C "Certificate of Disability" will be included with your confirmation email for your convenience.

Once your application is received and reviewed you will be notified of your eligibility to participate.

If you have questions about this service, the application form or need the application form in an alternate format please call: 724-465-2140 or 1-800-442-6928. You may also email pwd@indigobus.com. Do not include any personal identifiable information in emails.

Note: The information provided in this application regarding your disability will be used to determine your eligibility for reduced fare transportation services under the PwD program. Other information within the form will be used for data collection purposes, to determine your eligibility for any additional transportation programs, and to provide you with the appropriate type of service. This information will be kept confidential and used only by professionals involved in evaluating your eligibility and in analyzing the program for future recommendations.

NOTE: You must have a valid email address to submit this form as a confirmation of your application will be emailed to you. If you do not have a valid email address, please download and complete the .pdf version of the application as per the instructions above. Thank you.

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This application is:

PART 1: GENERAL INFORMATION

Do you have a disability according to the Americans with Disabilities Act (ADA) definition below?


PART 2: WRITTEN VERIFICATION THAT YOU ARE A PERSON WITH A DISABILITY

Written verification by a knowledgeable organization or qualified individual that you are a person with a disability is required to participate in the PwD project.

1. If you have written verification of a disability:

You may already have written verification that you are a person with a disability from a service organization by having an identification card, a written assessment of your disability, etc. If so, send a copy of this information to the transportation provider listed at the top of this form. If not, you will need to ask an organization or individual listed below to verify, in writing, that you are a person with a disability according to the ADA definition and then send it to the transportation provider listed at the top of this form.

Please check the organization or individual whose written verification you are submitting with your application form.

2. If you do not have written verification of a disability:

Please fill out a certification of disability form. It provides verification of a disability according to the definition in the Americans with Disabilities Act. This form can be used to acquire the necessary information for verifying a disability from a qualified health professional. Download Attachment C of the .pdf version of this application . After you complete the written certification, you may attach it to this application.


PART 3: INCOME AND HOUSEHOLD RELATED DATA

Passenger income related data is being collected for further decision-making regarding the project. THIS INFORMATION WILL NOT BE USED TO DETERMINE ELIGIBILITY FOR DISCOUNTED FARES UNDER THE PwD PROGRAM. Please check the appropriate space in each column:


PART 4: AVOIDING DUPLICATION OF TRANSPORTATION SERVICES

Transportation services provided under the PwD project are not to be provided in place of any current transportation services that you already receive.

1. Do you now receive any transportation services or are any of your transportation costs paid for by another program or organization?

If Yes, please complete all that apply from the following list.

2. If you are not registered for Medical Assistance (MA), you may qualify. If appropriate, you will be referred to the County Assistance Office (CAO) for a determination of eligibility for MA and other programs.

(01/02/1955 format)

PART 5: INFORMATION SO WE MAY SERVE YOU BETTER

1. Is your disability permanent?
(A standard definition of a permanent disability is one that lasts for 12 months or longer.)

2.

3. What is the nature of your disability? Check those that apply.

(please see question 4 below)

4. Please check all mobility aids that apply.

5. Do you require the services of a personal care attendant or escort when you travel? (A personal care attendant or escort is a person that you need to assist you during the trip or at your origin or destination)

If you need a personal attended, you may complete Supplement D and attach it to this form. Supplement D - Application for Attendant


6. Emergency Contact Optional

7. Is there anything else you want us to know so we can serve you better?



PART 6: RELEASE OF INFORMATION and YOUR CERTIFICATION OF THE APPLICATION FORM

Release of Information

Name of the Person Who Completed This Form:

If the person who completed this form is not the applicant, you must provide the following information:

I understand that the purpose of this application is to determine if I am eligible to participate in the PwD project. I certify that the information contained in this application is correct and truthful to the best of my knowledge.

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