BRAG Lifeline Mobility 2026

BRAG Lifeline Mobility 2025 Client Application

Complete and submit the following application with all verification documentation and any correlating forms if there is not enough space to provide the requested information. Applications are reviewed in 5-10 business days. Additional documents may be requested during this time. Requested documents are due within 10 business days or the application will be closed. Qualified applicants will proceed to an intake. For questions, assistance completing the application or to request an accommodation, contact the mobility specialist.
Applicants Full Name*
Application Date*

MonthDayYear
Address*

Home Address

Street Address Line 2

CityState

Zip
Household Information

Complete the following table for all household members. An email address and phone number is required for each adult applying for the program, except dependents/minors who need to have their guardian's name listed instead. Identification documents are required for all household members. Disability documentation is not required but may result in additional funding. Households with 4+ people, complete the Additional Household Members section of the Additional Information Form.

Relationship (to the applicant)

Phone Number (or guardian name) Email Address (or guardian name) Date of Birth

Disability Employed Applying for the program?

All household members that are not a minor/dependent need to sign. Warning: Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.
Applicant Information
Full Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Proof of Birthdate*

Photo ID, Birth Certificate, Passport
Cancelof
Disabled*

YESNO
Proof of disability*

Cancelof
Employed*

YESNO
Proof of Income*

Last 30 days
Cancelof
Applying for the program?*

YESNO
Household Member #1
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of Birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of Income

Last 30 days
Cancelof
Applying for the program?

YESNO
Household Member #3
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of Birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of income

Last 30 days
Cancelof
Applying for the program?

YESNO
Household Member #4
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of Birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of Income

Last 30 days
Cancelof
Applying for the program?

YESNO
Household Member #5
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of Income

Last 30 days
Cancelof
Applying for the program?

YESNO
Household Member #6
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of Birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of Income

Last 30 days
Cancelof
Applying for the program?

YESNO
Household Member #7
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of Birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of Income

Last 30 days
Cancelof
Applying for the program?

YESNO
Household Member #8
Full Name
Relationship to the applicant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Proof of Birthdate

Photo ID, Birth Certificate, Passport
Cancelof
Disabled

YESNO
Proof of Disability

Cancelof
Employed

YESNO
Proof of Income

Last 30 days
Cancelof
Applying for the program?

YESNO
Applicant Signature*

Clear
Date*

MonthDayYear
Applicant Signature

Clear
Date

MonthDayYear
Date
BRAG Lifeline Mobility 2025 Client Application
SELF-DECLARATION OF HOUSEHOLD INCOME
Complete the household income and deduction table for the previous month. Use empty slots if two people have the same type of income or other income types. Proof of income documentation must be included with this application. Gross income for all household members must be disclosed or the application will be denied. Medical expenses, child support and alimony paid are eligible deductions. Proof of payment for expenses must be attached to be considered. If more space is required complete the Additional Income and Deductions section on the Additional Information Form.

MONTHLY HOUSEHOLD INCOME & DEDUCTIONS
MONTH
Last 30 days
Income Type
Employment/Self Employment
Monthly Amount
Income Source
(i.e. employment name, self-employment)
Household Member
Individual receiving income
Unemployment
Monthly Amount
Income Source
Household Member
Individual receiving income
Worker Compensation
Monthly Amount
Income Source
Household Member
Individual receiving income
Social Security
Monthly Amount
Income Source
Household Member
Individual receiving income
Pension/Retirement
Monthly Amount
Income Source
Household Member
Individual receiving income
Veteran Benefits
Monthly Amount
Income Source
Household Member
Individual receiving income
Alimony
Monthly Amount
Income Source
Household Member
Individual receiving income
Child Support
Monthly Amount
Income Source
Household Member
Individual receiving income
Assistance from family or friends
Monthly Amount
Income Source
Household Member
Individual receiving income
Adult receiving no income
Household Member
Medical Expense

Please only list medical expenses that have been paid
Medical Expense Description
(i.e. pharmacy, doctor visit, dental visit)
Amount
Paid to
Paid by
Medical Expense Description
(i.e. pharmacy, doctor visit, dental visit)
Amount
Paid to
Paid by
Medical Expense Description
(i.e. pharmacy, doctor visit, dental visit)
Amount
Paid to
Paid by
All household members that are not a minor/dependent need to sign. Warning: Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Applicant Signature

Clear
Date

MonthDayYear
Date
Applicant Signature

Clear
Date

MonthDayYear
Date
Applicant Signature

Clear
Date

MonthDayYear
Date
BRAG Lifeline Mobility I Additional Income & Deductions Form
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Applicant Information

Household Member #1

Household Member #3

Household Member #4

Household Member #5

Household Member #6

Household Member #7

Household Member #8

SELF-DECLARATION OF HOUSEHOLD INCOME

Income Type

Medical Expense