Lifeline Mobility Voucher Program
2024 Client Application
GENERAL INFORMATION
Full Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Address
*
Street Address -or- Experiencing Homelessness
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email Address
ELIGIBILITY QUESTIONS
1. Are you over the age of 60?
*
YES
NO
2. Do you have a disability?
*
SHORT TERM
LONG TERM
NONE
If short term, briefly describe the disability and the expected length:
3. How many people live in your household?
*
4. What is your household's monthly income?
*
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MONTHLY TRIP INFORMATION
Fill in the following details for program eligible trips you usually take each month. Public transportation cannot be available due to hours of operation or lack based on participant location or destination for a trip to qualify. Additional trip information can be emailed to jennyr@brag.utah.gov if more than six are needed.
Trip Purpose
*
Write a short 1-5 word description of the trip purpose.
Trip Category
*
Please Select
Medical Health Services
Mental Health Services
Medicine and Medical Supply
Community Services
Education
Employment
Select an eligible category.
Destination City
*
List the destination city for the trip.
Number of Trips per Month
*
Average number of times this sort of trip is taken.
Round Trip Mileage
*
Number of miles to and from the destination.
Trip Purpose
Enter a short 1-5 word description of the trip.
Trip Category
Please Select
Medical Health Services
Mental Health Services
Medicine and Medical Supply
Community Services
Education
Employment
Select an eligible category.
Destination City
List the destination city for the trip.
Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Trip Purpose
Enter a short 1-5 word description of the trip.
Trip Category
Please Select
Medical Health Services
Mental Health Services
Medicine and Medical Supply
Community Services
Education
Employment
Select an eligible category.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Trip Purpose
Enter a short 1-5 word description of the trip.
Trip Category
Please Select
Medical Health Services
Mental Health Services
Medicine and Medical Supply
Community Services
Education
Employment
Select an eligible category.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Trip Purpose
Enter a short 1-5 word description of the trip.
Trip Category
Please Select
Medical Health Services
Mental Health Services
Medicine and Medical Supply
Community Services
Education
Employment
Select an eligible category.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Trip Purpose
Enter a short 1-5 word description of the trip.
Trip Category
Please Select
Medical Health Services
Mental Health Services
Medicine and Medical Supply
Community Services
Education
Employment
Select an eligible category.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
VERIFICATION DOCUMENT
Attach a valid documentation verifying low income, disability, or senior status below.
*
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I verify the information I provided for this application is accurate to the best of my knowledge.
Applicant Signature
Date
-
Month
-
Day
Year
Submit
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