Movability Guaranteed Ride Home Reimbursement Form
Participant Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your employer
*
Your work address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Trip Details
Date of ride
*
-
Month
-
Day
Year
Date
Pickup time
*
Hour Minutes
AM
PM
AM/PM Option
Dropoff location
*
Mode of transportation used (e.g. Uber, Lyft, Taxi, etc.)
*
Reason for emergency ride (select one)
*
Personal illness or emergency
Family illness or emergency
Unscheduled overtime (must be authorized by supervisor)
Home maintenance emergency
Carpool driver had to leave unexpectedly
Other
Receipt Submission
Upload a copy of your ride receipt (PDF, JPEG, or PNG)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Total amount requested for reimbursement:
*
Upload verification of emergency event (e.g. documentation from school showing a child was sent home, documentation of family/home emergency, supervisor verification of unscheduled overtime, etc.)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Acknowledgments
*
I confirm that this ride was taken due to an eligible emergency and that I was commuting via a sustainable mode (carpool, vanpool, transit, bike, or walk) when the need for a guaranteed ride home occurred.
I understand that GRH is limited to five [5] uses per year and reimbursement is subject to program limits.
I certify that the information provided is accurate and understand that fraudulent claims may result in loss of GRH privileges.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: