Marin Access Low-Income Fare Assistance Program Application

Use this application to submit information needed to determine your eligibility for the expanded Marin Access Low-Income Fare Assistance program. Eligible riders will receive $20 of credit per month to use for trips on Marin Access services and will have the option of receiving a free pass to use on Marin Transit local bus service.

To qualify for the LIFA program you must be age 65+ or eligible for ADA paratransit, a resident of Marin County, and either:

be enrolled and eligible for Medi-Cal

OR

demonstrate annual income that is at or below the current Elder Economic Index standard.

Complete this application and submit all required documentation by May 15, 2020; this will ensure that you are enrolled into the program and will receive benefits starting July 1, 2020. Your Marin Access ID can be found in the upper right corner of the letter mailed to you or by request to the Travel Navigator team.

Forms received after May 15 will be processed within 6 weeks of receipt. Forms that are incomplete will not be processed. A completed application includes responses to all questions and receipt of all necessary documentation.

Documentation can be submitted online through this form, by email to travelnavigator@marintransit.org or by mail to Marin Access | 711 Grand Avenue, Suite 110, San Rafael, CA 94901.

If you have any questions about how to complete this form, contact the Marin Access Travel Navigators at 415.454.0902.

Question Title

* 1. First Name:

Question Title

* 2. Last Name:

Question Title

* 3. Date of Birth:

Date

Question Title

* 4. Marin Access ID:

Question Title

* 5. I would like to receive a free Marin Access pass to use on local buses.

Question Title

* 6. I am enrolled in Medi-Cal

Question Title

* 7. My Medi-Cal ID Number is (found on the front of your Medi-Cal Benefits Card):

Question Title

* 8. My Medi-Cal Card Issue Date is (found on the front of your Medi-Cal Benefits Card):

Date

Question Title

* 9. My annual income is:

Question Title

* 10. Describe your living situation.

  Single Couple
Owner Without Mortgage
Owner With Mortgage
Renter

Question Title

* 11. If you are applying based on your income, you will need to submit documentation demonstrating your annual income. Choose from the options below to let us know what form of documentation we can expect.

Question Title

* 12. Upload income documentation here.

PDF, DOC, DOCX, JPG, JPEG file types only.
Choose File

Question Title

* 13. Check ALL of the the boxes below to agree to each statement.

0 of 13 answered
 

T