Fare Assistance Program - VIA Metropolitan Transit

Application Form

Please submit the following application for the requesting organization.

Only 501(c)(3) non-profit, social service and governmental/public organizations in good standing located within the VIA service area serving clients who are low-income and/or living below the federal poverty level are eligible to apply for VIA’s Fare Assistance Program.

Fare Assistance Program

Organization Name *

Program Name(s) *

Street Address *

City *

State *

ZIP Code *

Application Contact/Representative *

Application Contact/Representative Title *

Mailing Address

Phone Number *

Fiscal Agent/Organization Treasurer *

Email Address *

Phone Number *

REQUIRED ATTACHMENTS

1. Include a copy of your Agency's IRS letter confirming 501(c)(3) eligibility as described by the Federal Internal Revenue Code

Maximum file size: 52.43MB

2. Include a copy of your Organization Bylaws, Charter or Annual Report

Maximum file size: 52.43MB

ORGANIZATION DESCRIPTION

1. Briefly describe the mission and purpose of your organization:

2. Describe specific services offered to low-income recipients or clients living below the poverty level provided by your organization:

3. How many clients are served by your organization annually and what percentage of those served will benefit from VIA’s Fare Assistance Program?

DESCRIPTION OF PROGRAM, FARE DISTRIBUTION AND USE

1. Describe how you will use transit fare to support your organization’s mission and your clients and the benefit you hope to achieve.

2. Describe the eligibility process you will use to determine the transportation needs of recipients.

3. Agency Representative administering program:

Your organization will be responsible for maintaining a log of clients receiving bus passes through VIA’s Fare Assistance Program. VIA will provide a document to participating organizations to record clients receiving passes and type of passes received. VIA may review the log quarterly to ensure that the passes purchased through VIA Fare Assistance Program comply with the purpose and intent of the program.

Email Address

Phone Number

4. WHAT TYPE OF BUS PASSES DO YOU ANTICIPATE PURCHASING TRHOUGH VIA’s FARE ASSISTANCE PROGRAM? (PLEASE CHECK ALL APPLICABLE BOXES)

Monthly Bus Pass (Half Fare)

Monthly Bus Pass (Full Fare)

Day Pass (Half Fare)

Day Pass (Full Fare)

7-Day Pass (Half Fare)

7-Day Pass (Full Fare)

VIAtrans tickets (Must be eligible and registered VIAtrans customers to ride this service)

CERTIFICATION

Electronic Signature of applying organization’s authorized representative

Title

Date

Electronic signature of organization’s authorized Chief Executive Officer/President (if different from applying representative)

Title

Date