Taxi Subsidy - Arlington Rides

Taxi Subsidy- Arlington Rides

This program provides discounted taxi rides for low-income seniors and persons with disabilities. Qualifying individuals receive a $5 discount per ride with a maximum of 20 rides per month.

Residents that qualify must be at or below 250% of the poverty guidelines.

BELOW 250% OF THE POVERTY GUIDELINES

1 person	2 poeple	3 people	4 people	5 people	6 people	7 people	8 people
$30,350	$41,150	$51,950	$64,450	$73,550	$84,350	$95,150	$105,950

If you have any questions, please contact Hannah Kane at 847-368-5793 or hkane@vah.com

Full Name

First NameLast Name
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
Gender
Members of Household

Household Member #2
Full Name

First NameLast Name
Relationship to Applicant
Date of Birth

MonthDayYear
Date
Gender
Is this family member an additional applicant?

YesNo
Household Member #3
Full Name

First NameLast Name
Relationship to Applicant
Date of Birth

MonthDayYear
Date
Gender
Is this family member an additional applicant?

YesNo
Household Member #4
Full Name

First NameLast Name
Relationship to Applicant
Date of Birth

MonthDayYear
Date
Gender
Is this family member an additional applicant?

YesNo

Required Attachements

Attach list of other household members to form

Low-income seniors (age 65 and up) and persons with disabilities (age 18 and up) - $5 per ride discount.

BELOW 250% OF THE POVERTY GUIDELINES

1 person	2 poeple	3 people	4 people	5 people	6 people	7 people	8 people
$30,350	$41,150	$51,950	$64,450	$73,550	$84,350	$95,150	$105,950

Please attach the following below.

PHYSICIAN CERTIFICATION OF DISABILITY (if under 65) OR CURRENT SSDI/SSI AWARD LETTER
IF APPLICABLE, ATTACH LIST OF ALL OTHER HOUSE MEMBERS. IDENTIFICATION FOR EACH MEMBER OF HOUSEHOLD: Driver’s license, State ID, with For children we will accept school forms with their name, all require Arlington Heights addresses.
LEASE OR MORTGAGE STATEMENT
UTILITY BILL: (Gas or electric bill)
TOTAL HOUSEHOLD INCOME: All that apply: 3 months pay stubs with length of pay period indicated OR current Disability, SSDI/SSI/Social Security Retirement, or Unemployment award letter OR W2 form OR Tax return (if it is the same as current amount).

Upload File(s)

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Sign Here*

First NameLast Name
Email
example@example.com
Signature
I hereby apply for participation in Arlington Rides offered by the Village of Arlington Heights. All information on this application is accurate. I authorize the Disability Services Coordinator to authenticate this information.
Should be Empty:

Taxi Subsidy- Arlington Rides

If you have any questions, please contact Hannah Kane at 847-368-5793 or hkane@vah.com

Members of Household

Household Member #2

Household Member #3

Household Member #4

Required Attachements