ORCA LIFT Card Renewal Application

You may apply for a renewal ORCA LIFT card if your ORCA LIFT card will expire in the next three months. You may use this secure online form if you receive food and/or medical benefits from the State of Washington. If we can verify your eligibility for ORCA LIFT, a new card will be mailed to you in 7-10 business days. If you have never had an ORCA LIFT card, please see orcalift.com  about applying for a card in person. *Required field.

Name

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* 1. Name

Previous name(s) if any

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* 2. Previous name(s) if any

Date of birth (mm/dd/yyyy)

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* 3. Date of birth (mm/dd/yyyy)

Mailing address

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* 4. Mailing address

Phone number (10 digits with no separators)

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* 5. Phone number (10 digits with no separators)

Email address

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* 6. Email address

Validate email address

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* 7. Validate email address

ORCA LIFT card number - eight digit number

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* 8. ORCA LIFT card number - eight digit number

Expiration date from the back of the card (mm/dd/yyyyy)

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* 9. Expiration date from the back of the card (mm/dd/yyyyy)

Do you have an active EBT card (food benefits)?

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* 10. Do you have an active EBT card (food benefits)?

Client ID# - 9 digit number that can be found at the top of your DSHS award letter.

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* 11. Client ID# - 9 digit number that can be found at the top of your DSHS award letter.

Do you receive medical benefits from the State of Washington?

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* 12. Do you receive medical benefits from the State of Washington?

Household size

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* 13. Household size

Do you have a smart phone?

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* 16. Do you have a smart phone?

How would you like us to contact you if we have questions? (check all that apply)

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* 17. How would you like us to contact you if we have questions? (check all that apply)

Please tell us how the discounted ORCA LIFT fare has affected your quality of  life. (We appreciate your comments and regret that we are unable to reply to any comments that we receive.)

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* 18. Please tell us how the discounted ORCA LIFT fare has affected your quality of  life. (We appreciate your comments and regret that we are unable to reply to any comments that we receive.)

I certify that my answers are true and complete to the best of my knowledge, and I give express permission to King County to obtain information to verify my eligibility for the ORCA LIFT Program, and I understand that, except as required by law, King County may use and/or retain portions of this personal information for low income fare verification only.

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* 19. I certify that my answers are true and complete to the best of my knowledge, and I give express permission to King County to obtain information to verify my eligibility for the ORCA LIFT Program, and I understand that, except as required by law, King County may use and/or retain portions of this personal information for low income fare verification only.

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