BRAG Lifeline Mobility Program Application

BRAG Lifeline Mobility Program Application
Application Information & Required Documentation
Thank you for your interest in applying. To help ensure your application is processed as quickly as possible, please carefully review the information below before submitting your paperwork.
Application Requirements
All applications must be:
- Completely filled out
- Signed
- Dated
Incomplete applications may delay processing or result in denial.

Client Eligibility:
- Applicants must reside in Box Elder, Cache or Rich County
- Applicants must be over the age of 60, or disabled, and low income
- Applicants are unable to use the public transit to a qualifed destination
Required Documentation
Proof of Income
Provide proof of all household income received within the last 30 days. Examples may include:
- Pay stubs
- Social Security award letters
- Pension statements
- Unemployment benefits
- Child support documentation
- Any other income verification
Photo Identification
Provide a valid photo ID for the applicant and any adults in the household. Examples include:
- Driver license
- State ID card
- Passport
- Other government-issued identification
Proof of Disability
If applicable, documentation verifying disability status must be included.
- Social Security disability award letter
- Physician statement
- Disability determination documentation
Medical Expense Deductions (If Applicable)
If medical deductions are listed on the application, proof of medical expenses paid within the last 30 days must be provided.
- Pharmacy receipts
- Medical receipts
- Insurance payment receipts
- Statements showing payments made

Qualified Trips
All trips will require admin approval. If a trip is not listed on your application, the driver will not receive reimbursement for the trip. Please list any of the following qualified trips on your application.
- Medical
- Pharmacy
- Nutrition
- Mental Health
- Social Service
- Education
- Employment
*Employment and Education trips for Box Elder County residents no longer qualify for reimbursement*
Processing Time
Please allow up to 10 business days for processing once all required documentation has been received.
Applications missing required information or documentation may experience delays.
Important Notice
Failure to provide all required documentation may result in denial of the application.
Please make sure all requested paperwork is included before submitting your application.
Additional Requirements After Approval
If an application is approved, additional documentation may be required depending on the applicant's situation.
In addition, all drivers will be required to complete any necessary training prior to participation or services being provided.
No exceptions will be made regarding required training.

MAILING ADDRESS	MOBILITY SPECIALIST	MOBILITY MANAGER
BRAG \| Lifeline Mobility 170 North Main Street Logan, UT 84321	Jenny Rodriguez (435) 713-1449 jennyr@brag.utah.gov	Alyssa Cronin (435) 713-1427 alyssac@brag.utah.gov

Lifeline Mobility Program Client Application
Complete and submit the following application with all required verification documentation. Applications may take up to 10 business days to process. Additional documents may be requested during the review process.

Failure to provide all required documentation may result in denial of the application.
Applicant Information
Applicant Full Name:
Application Date:

MonthDayYear
Date
Gender:
Date of Birth:

MonthDayYear
Date
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Household Information
List all household members living in the home.

Household Information

Rows	Full Name	Relationship	Date of Birth	Phone Number	Email Address	Disabled?	Applying?
1
2
3
4
5

Monthly Household Income

Monthly Household Income Provide all household income received within the last 30 days.

Rows	Income Type	Name of Recipient	Amount Received	How often is this income received?
1
2
3
4
5
6

Medical Expense Deductions (If Applicable)

Medical Expense Deductions (If Applicable) List any medical expenses paid within the last 30 days and attach proof of payment.

Rows	Expense Description	Amount Paid	Paid To	Paid By
1
2
3
4
5

Trip Information

Trip Information Please list all qualified trip addresses (medical, mental health, pharmacy, grocery, social service, education, & employment) *Employment and Eduction trips for Box Elder County residents no longer qualify*

Rows	Destination	Address	Trip purpose
1
2
3
4
5
6
7
8
9
10
11
12

Required Documentation Checklist
Additional Requirements After Approval
If an application is approved, additional documentation may be required depending on the applicant's situation.
A required driver training must be completed prior to services being provided.
No exceptions will be made regarding required training.
Applicant Certification & Signature
I acknowledge that I have fully read and understand all information contained in this application, including the program guidelines, eligibility requirements, and participant responsibilities. I certify that all information provided in this application and any supporting documentation is true, complete, and accurate to the best of my knowledge. I understand that providing false, misleading, incomplete, or intentionally inaccurate information will result in the immediate denial of my application and may result in disqualification from future participation in the program. By signing below, I acknowledge that I have read, understand, and agree to abide by all terms, conditions, and requirements of the program.
Applicant Signature:
Date:

MonthDayYear
Date
Please Attach The Following Verifications
Proof of income for the last 30 days

Cancelof
Proof of disability (if applicable)

Cancelof
Proof of medical deductions paid within the last 30 days (if applicable)

Cancelof
Valid photo identification

Cancelof
Should be Empty:

BRAG Lifeline Mobility Program Application

Application Information & Required Documentation

Application Requirements

Required Documentation

Proof of Income

Photo Identification

Proof of Disability

Medical Expense Deductions (If Applicable)

Qualified Trips

Processing Time

Important Notice

Additional Requirements After Approval

Lifeline Mobility Program Client Application

Applicant Information

Household Information

Monthly Household Income

Medical Expense Deductions (If Applicable)

Trip Information

Additional Requirements After Approval

Applicant Certification & Signature

Please Attach The Following Verifications