Battle Creek, MI

Reduced Fare Form

Leave This Blank:

Applicant's Full Name:

Address:

City:

State:

Zip:

I hereby authorized the release of this information to Battle Creek Transit or it's designee for the purpose of determining eligibility for Reduced Fare. This form is confidential and will be used by Battle Creek Transit (BCT) staff and Department of Transportation authorized officials for transportation purposes and compliance reviews only.

Type Full Name:

Date:

PARTICIPATING AGENCY OR HEALTH CARE PROVIDER - You are being asked to determine if this applicant meets the definition of "Disabled
Person" in 49 CFR, part 27 (see reverse) and should be eligible to use BCT's services at reduced fare rates.

I. Does the applicant have a disability as defined in 49 CFR, part 27 that would quality them for reduced fare?

Yes

2. In general terms, please describe the applicant's characteristics based on the definition of a disabled person (see reverse) which would quality the applicant for reduced fares.

3. Is the disability permanent or temporary?

4. If TEMPORARY, length of disability:

Months:

Years:

Participating Agency or Health Care Provider information:

Name of Agency:

Name:

Phone number:

Type Full Name:

Date:

Battle Creek Transit has a Reduced Fare Program for eligible disabled (as defined in 49 CFR, part 27) and elderly persons. To be eligible for reduced fare, an individual must present a Medicare Card issued pursuant to Sections II and XVII of the Social Security Act, an official State pictured ID showing you are the age of 60 or older, or a BCT Reduced Fare ID Card to the BCT driver upon request.

To be issued a Battle Creek Transit Reduced Fare ID Card this certification form must be turned into Battle Creek Transit. This form may be turned in at Battle Creek Transit, 339 West Michigan Ave, Battle Creek, MI 49037, Monday through Friday 8:00 AM -12:00
PM and 1 :00 PM -5:00 PM or may be faxed in at 269-966-3652. Determinations may take up to 10 working days. Applications must be signed and complete.

49 CFR defines a "disabled person" as any person who (a) has a physical or mental impairment that substantially limits one or more major life activities, (b) has a record of such an impairment, or (c) is regarded as having such an impairment. As used in this definition, the phrase:

a. Physical or mental impairment means (i) any physiological disorder or condition, cosmetic disfigurement, or anatomical
loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory,
including speech organs; cardiovascular, reproductive; digestive; genito~urinary; hemic and lymphatic; skin; and endocrine;
or (ii) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental
illness, and specific learning disabilities. The term physical or mental impairment includes, but is not limited to, such
diseases and conditions as orthopedic, visual, speech, and hearing impairments; cerebral palsy; epilepsy; muscular
dystrophy; multiple sclerosis; cancer; heart disease; mental retardation; emotional illness; drug addiction; and alcoholism.

b. Major life activities meanS functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, leaming, and working.

c. Has a record of such an impairment means has a history of, or has been classified, or misclassified, as having a mental or physical impairment that substantially limits one or more major life activities.

d. Is regarded as having an impairment means:
1. Has a physical or mental impairment that does not substantially limit major life activities but that is treated by a recipient as constituting such a limitation;
2. Has a physical or mental impairment that substantially limits major life activity only as a result of the attitudes of others toward such an impairment; or
3. Has none of the impairnlents set forth in paragraph a. of this definition, but is treated by a recipient as having such impairment

Upon expiration of a Temporary Reduced Fare ID card, a new application must be turned in for review and a new ID card issued and paid for.

If you are determined to be eligible for Reduced Fare you will be called and asked to come in to Battle Creek Transit to take a picture and be issued a Battle Creek Transit Reduced Fare ID Card. There is a $2.00 processing fee for the ID card.

ELIGIBILITY DOES NOT START UNTIL THE ID CARD IS ISSUED TO YOU.

If you are determined to be ineligible, a letter stating the ineligible determination will be mailed to you.

Fraudulently obtaining, copying or using identification cards to utilize BCT services at a reduced rate is a crime and may be prosecuted according to appropriate Federal and State laws.

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