SARASOTA COUNTY AREA TRANSIT BUS PASS APPLICATION

To enroll in the SCAT Bus Pass Program, please fill out the application and return it with the $8.00 monthly co-pay, to Sarasota County Area Transit (SCAT), 5303 Pinkney Avenue, Sarasota, FL 34233. Please send cash, a check or money order payable to SCAT. You will receive the bus pas once the $8.00 co-pay is received. All bus pass clients are required to pay the $8.00 co-pay. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Name: Medicaid Number: Social Security Number: Date of Birth: Telephone: Are you attending school? If yes, then submit proof of registration.

Do you have any other means of transportation including family or friends? Yes / No Are you presently employed? Yes / No If yes, then submit proof of employment. Are you able to use the fixed route bus system for your appointments? Yes / No How many trips per month do you anticipate? * What is your Monthly/Annual Household Income? /
(Submit copy of pay stub, tax return, social security, etc.) * The State of Florida Transportation Disadvantage Commission Handbook, Chapter 427, Florida Statutes, states in part the following: 427.011-427.017(1) Transportation: Disadvantaged means those persons who because of a physical or mental disability, income statue, age or who for other reasons are unable to transport themselves or to purchase transportation and are, therefore, dependent upon other to obtain access to health care, employment, education, shopping, social activities, or other life sustaining activities..

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Homes address:

SARASOTA COUNTY TRANSPORTATION AUTHORITY POLICY ON THE COLLECTION OF SOCIAL SECURITY NUMBERS
Sarasota County Transportation Authority collects your Social Security Number for the following purposes: Classification of accounts; identification and verification; credit worthiness; billing and payments; data collection, reconciliation, tracking, benefit processing, and tax reporting, as a unique identifier and for search purposes.

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