REDUCED FARE PERMIT
WZ^KE^t/d,/^/>/d/^
WZD/dWW>/d/KE
ZdWĞƌƐŽŶƐǁŝƚŚŝƐĂďŝůŝƟĞƐ
Ride Free Permit
͘ ƉƉůŝĐĂŶƚƐǁŝƚŚĚŝƐĂďŝůŝƟĞƐƌĞĐĞŝǀŝŶŐ^ŽĐŝĂů
^ĞĐƵƌŝƚLJŽƌ^^/ďĞŶĞĮƚƐ
͘ DĞĚŝĐĂƌĞĐĂƌĚŚŽůĚĞƌƐƌĞĐĞŝǀŝŶŐ^ŽĐŝĂů
^ĞĐƵƌŝƚLJďĞŶĞĮƚƐ͕ŝŶĐůƵĚŝŶŐƉĞƌƐŽŶƐǁŚŽĚŽ
ŶŽƚŚĂǀĞĂĚŝƐĂďŝůŝƚLJĂŶĚĂƌĞƵŶĚĞƌƚŚĞ
ĂŐĞŽĨϲϱ
͘ sĞƚĞƌĂŶƐƌĞĐĞŝǀŝŶŐƐĞƌǀŝĐĞͲƌĞůĂƚĞĚĚŝƐĂďŝůŝƚLJ
ďĞŶĞĮƚƐ
RTA Persons with Disabilites
Reduced Fare Permit
͘ ƉƉůŝĐĂŶƚƐǁŝƚŚƉŚLJƐŝĐĂů͕ŚĞĂƌŝŶŐ͕ŵŽďŝůŝƚLJ͕
ŵĞŶƚĂů͕ǀŝƐƵĂůŽƌĐŽŐŶŝƟǀĞĚŝƐĂďŝůŝƟĞƐΎ
dŚĞZdWĞƌƐŽŶƐǁŝƚŚŝƐĂďŝůŝƟĞƐZĞĚƵĐĞĚ&ĂƌĞ
WƌŽŐƌĂŵĂůůŽǁƐŝŶĚŝǀŝĚƵĂůƐǁŝƚŚĚŝƐĂďŝůŝƟĞƐĂŐĞ
ϲϰŽƌƵŶĚĞƌ͕ǁŚŽĂƌĞŶŽƚĞůŝŐŝďůĞĨŽƌƚŚĞK
ĞŶĞĮƚĐĐĞƐƐWƌŽŐƌĂŵ͕ƚŽƌŝĚĞŽŶd͕DĞƚƌĂ
ĂŶĚWĂĐĞĮdžĞĚƌŽƵƚĞďƵƐĂŶĚƌĂŝůƐĞƌǀŝĐĞĂƚĂ
ƌĞĚƵĐĞĚƌĂƚĞ͘
* Persons with episodic disorders may be
eligible for a RTA Reduced Fare Permit based
ŽŶĨƵŶĐƟŽŶĂůĂďŝůŝƟĞƐǁŚĞŶƚŚĞĚŝƐŽƌĚĞƌŝƐŶŽƚ
under control.
IF APPROVED, APPLICANTS WILL RECEIVE THEIR RTA RIDE FREE PERMIT
KZZh&ZWZD/dt/d,/Eϯͳϰt<^͘
Zd͕WKŽdžϴϲϮϭ͕&ŽƌƚtĂLJŶĞ͕/EϰϲϴϵϴͲϴϲϮϭ͕WŚŽŶĞ͗ϯϭϮͲϵϭϯͲϯϭϭϬ
RIDE FREE PERMIT
dŚĞZdWĞƌƐŽŶƐǁŝƚŚŝƐĂďŝůŝƟĞƐZŝĚĞ&ƌĞĞ
Permit allows qualifying customers with
ĚŝƐĂďŝůŝƟĞƐƚŽƌŝĚĞĂƚŶŽĐŽƐƚŽŶd͕DĞƚƌĂ
ĂŶĚWĂĐĞĮdžĞĚƌŽƵƚĞďƵƐĂŶĚƌĂŝůƐĞƌǀŝĐĞ͘
ƉƉůŝĐĂŶƚƐŵƵƐƚďĞĂŐĞϲϰŽƌƵŶĚĞƌĂŶĚ
ĞŶƌŽůůĞĚŝŶƚŚĞĞŶĞĮƚĐĐĞƐƐWƌŽŐƌĂŵ
ĂĚŵŝŶŝƐƚĞƌĞĚďLJƚŚĞ/ůůŝŶŽŝƐĞƉĂƌƚŵĞŶƚŽŶ
ŐŝŶŐ;KͿ͘&ŽƌŵŽƌĞŝŶĨŽƌŵĂƟŽŶĂďŽƵƚƚŚĞ
KĞŶĞĮƚĐĐĞƐƐWƌŽŐƌĂŵǀŝƐŝƚǁǁǁ͘ŝůůŝŶŽŝƐ͘
ŐŽǀͬĂŐŝŶŐŽƌĐĂůůϭͲϴϬϬͲϮϱϮͲϴϵϲϲ͘
tŚŽYƵĂůŝĮĞƐĨŽƌĂWĞƌƐŽŶƐǁŝƚŚ
ŝƐĂďŝůŝƟĞƐZĞĚƵĐĞĚ
Fare Permit?
WZ^KE^t/d,/^/>/d/^WZD/dWW>/d/KE
RIDE FREE APPLICATION
INSTRUCTIONS
REDUCED FARE APPLICATION
INSTRUCTIONS
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•
•
•
•
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ƉƉůLJĨŽƌƚŚĞ/ůůŝŶŽŝƐKĞŶĞĮƚĐĐĞƐƐ
WƌŽŐƌĂŵ͗
– &ƌŽŵĂŶLJĐŽŵƉƵƚĞƌ͕ǀŝƐŝƚƚŚĞ/ůůŝŶŽŝƐ
ĞƉĂƌƚŵĞŶƚŽĨŐŝŶŐĞŶĞĮƚĐĐĞƐƐ
WƌŽŐƌĂŵǁĞďƐŝƚĞĂƚǁǁǁ͘ŝůůŝŶŽŝƐ͘ŐŽǀͬĂŐŝŶŐ
ĂŶĚĐůŝĐŬŽŶƚŚĞ͞ĞŶĞĮƚĐĐĞƐƐ͟ƚĂď
– &ŽƌŝŶͲƉĞƌƐŽŶĂƐƐŝƐƚĂŶĐĞ͕ĐĂůůƚŚĞ/ůůŝŶŽŝƐ
ĞƉĂƌƚŵĞŶƚŽŶŐŝŶŐƚŽůŽĐĂƚĞĂůŽĐĂƟŽŶ
ŶĞĂƌLJŽƵƚŚĂƚĐĂŶƉƌŽǀŝĚĞĂƐƐŝƐƚĂŶĐĞĂƚ
;ϴϬϬͿϮϱϮͲϴϵϲϲ
ŽŵƉůĞƚĞƉĂŐĞϯŽĨƚŚŝƐĂƉƉůŝĐĂƟŽŶ
^ĞŶĚƚŚĞĂƉƉůŝĐĂƟŽŶ͕ĂĐŽƉLJŽĨLJŽƵƌĐƵƌƌĞŶƚ
ŐŽǀĞƌŶŵĞŶƚŝƐƐƵĞĚ/ĐĂƌĚ;ƐƵĐŚĂƐĂĚƌŝǀĞƌ͛Ɛ
ůŝĐĞŶƐĞ͕ƐƚĂƚĞ/͕ƉĂƐƐƉŽƌƚŽƌĂůŝĞŶƌĞŐŝƐƚƌĂƟŽŶ
ĐĂƌĚͿĂŶĚĂϮ͟ďLJϮ͟ĐŽůŽƌƉŚŽƚŽƚŚĂƚĐůĞĂƌůLJ
ƐŚŽǁƐLJŽƵƌĨĂĐĞƚŽƚŚĞZdŝŶƚŚĞĞŶǀĞůŽƉĞ
ƉƌŽǀŝĚĞĚŽƌŵĂŝůƚŽZd͕WKŽdžϴϲϮϭ͕&Žƌƚ
tĂLJŶĞ͕/EϰϲϴϵϴͲϴϲϮϭ
•
ŽŵƉůĞƚĞƉĂŐĞϯŽĨƚŚŝƐĂƉƉůŝĐĂƟŽŶ
WƌŽǀŝĚĞƉƌŽŽĨŽĨĚŝƐĂďŝůŝƚLJͬDĞĚŝĐĂƌĞĞůŝŐŝďŝůŝƚLJ
/ĨLJŽƵƵƐŝŶŐĂĚŽĐƚŽƌ͛ƐǀĞƌŝĮĐĂƟŽŶĂƐƉƌŽŽĨ
ŽĨĚŝƐĂďŝůŝƚLJ͕ƉůĞĂƐĞĐŽŵƉůĞƚĞƉĂŐĞϰŽĨƚŚŝƐ
ĂƉƉůŝĐĂƟŽŶĂŶĚŝŶĐůƵĚĞĂĚŽĐƚŽƌ͛ƐƐƚĂƚĞŵĞŶƚ
^ĞŶĚƚŚĞĂƉƉůŝĐĂƟŽŶ͕ĂĐŽƉLJŽĨLJŽƵƌĐƵƌƌĞŶƚ
ŐŽǀĞƌŶŵĞŶƚŝƐƐƵĞĚ/ĐĂƌĚ;ƐƵĐŚĂƐĂĚƌŝǀĞƌ͛Ɛ
ůŝĐĞŶƐĞ͕ƐƚĂƚĞ/͕ƉĂƐƐƉŽƌƚŽƌĂůŝĞŶƌĞŐŝƐƚƌĂƟŽŶ
ĐĂƌĚͿ͕ĂϮ͟ďLJϮ͟ĐŽůŽƌƉŚŽƚŽƚŚĂƚĐůĞĂƌůLJƐŚŽǁƐ
LJŽƵƌĨĂĐĞĂŶĚLJŽƵƌĚŽĐƚŽƌƐƐƚĂƚĞŵĞŶƚ;ŝĨ
ĂƉƉůŝĐĂďůĞͿƚŽƚŚĞZdŝŶƚŚĞĞŶǀĞůŽƉĞƉƌŽǀŝĚĞĚ
ŽƌŵĂŝůƚŽZd͕WKŽdžϴϲϮϭ͕&ŽƌƚtĂLJŶĞ͕/E
ϰϲϴϵϴͲϴϲϮϭ
PROOF OF DISABILITY/MEDICARE ELIGIBILITY
ŚŽŽƐĞĂŶĚƐƵďŵŝƚŽŶĞŽĨƚŚĞŽƉƟŽŶƐůŝƐƚĞĚďĞůŽǁ͗
(DOCUMENTS VERIFYING DISABILITY MUST NOT BE MORE THAN 12 MONTHS OLD)
͘ ^ŽĐŝĂů^ĞĐƵƌŝƚLJsĂůŝĚĂƟŽŶ͘ƉƉůŝĐĂŶƚƐŵƵƐƚƉƌŽǀŝĚĞĂĐƵƌƌĞŶƚƉƌŝŶƚŽƵƚŽĨƚŚĞŝƌ^ŽĐŝĂů^ĞĐƵƌŝƚLJĞŶĞĮƚƐ
ƐƚĂƚĞŵĞŶƚƚŚĂƚƐƚĂƚĞƐƚŚĞǁŽƌĚƐ͕͞ĚŝƐĂďůĞĚŝŶĚŝǀŝĚƵĂů͟ŽƌƚŚĞůĞƩĞƌƐ͞/͟ĂŌĞƌƚŚĞŝƌ^ŽĐŝĂů^ĞĐƵƌŝƚLJ
ŶƵŵďĞƌŽƌĐůĂŝŵŶƵŵďĞƌ͘Ύ
͘ DĞĚŝĐĂƌĞsĂůŝĚĂƟŽŶ͘ ƉƉůŝĐĂŶƚƐŵƵƐƚƐƵďŵŝƚƚŚĞĨŽůůŽǁŝŶŐƚǁŽ;ϮͿĨŽƌŵƐ͗
ϭ͘ ĐŽƉLJŽĨƚŚĞŝƌDĞĚŝĐĂƌĞĐĂƌĚ;ŶŽƚDĞĚŝĐĂŝĚͿ
— AND —
Ϯ͘ ĐƵƌƌĞŶƚ^ŽĐŝĂů^ĞĐƵƌŝƚLJĞŶĞĮƚ^ƚĂƚĞŵĞŶƚΎ
͘ sĞƚĞƌĂŶƐsĂůŝĚĂƟŽŶ͘/ĨƚŚĞĂƉƉůŝĐĂŶƚŚĂƐĂƐĞƌǀŝĐĞͲĐŽŶŶĞĐƚĞĚĚŝƐĂďŝůŝƚLJ͕ŚĞͬƐŚĞŵƵƐƚƐƵďŵŝƚĂĐŽƉLJŽĨ
ĂďĞŶĞĮƚůĞƩĞƌĨƌŽŵƚŚĞsĞƚĞƌĂŶƐĚŵŝŶŝƐƚƌĂƟŽŶ͘
͘ ŽĐƚŽƌƐsĂůŝĚĂƟŽŶ͘ƉƉůŝĐĂŶƚŵƵƐƚƐƵďŵŝƚƚŚĞĨŽůůŽǁŝŶŐƚǁŽ;ϮͿĨŽƌŵƐ͗
ϭ͘ dŚĞďĂĐŬŽĨƚŚŝƐĂƉƉůŝĐĂƟŽŶĨŽƌŵĐŽŵƉůĞƚĞĚďLJƚŚĞŝƌĚŽĐƚŽƌ
— AND —
Ϯ͘ ĚŽĐƚŽƌƐƚĂƚĞŵĞŶƚĚĞƐĐƌŝďŝŶŐƚŚĞŶĂƚƵƌĞŽĨƚŚĞŝƌĚŝƐĂďŝůŝƚLJŽŶƉƌŽĨĞƐƐŝŽŶĂůůĞƩĞƌŚĞĂĚŽƌ
ƉƌĞƐĐƌŝƉƟŽŶĨŽƌŵ͘
ΎďĞŶĞĮƚǀĞƌŝĮĐĂƟŽŶůĞƩĞƌŽƌ^ŽĐŝĂů^ĞĐƵƌŝƚLJĞŶĞĮƚ^ƚĂƚĞŵĞŶƚĐĂŶďĞŽďƚĂŝŶĞĚďLJĐĂůůŝŶŐƚŚĞ^ŽĐŝĂů
^ĞĐƵƌŝƚLJĂĚŵŝŶŝƐƚƌĂƟŽŶŽĸĐĞĂƚϴϬϬͲϳϳϮͲϭϮϭϯ͕ďLJǀŝƐŝƟŶŐĂŶLJ^ŽĐŝĂů^ĞĐƵƌŝƚLJĚŵŝŶŝƐƚƌĂƟŽŶKĸĐĞ͕Žƌ
ŽŶůŝŶĞĂƚǁǁǁ͘ƐƐĂ͘ŐŽǀͬŵLJĂĐĐŽƵŶƚ͘
Ϯ
WZ^KE^t/d,/^/>/d/^WZD/dWW>/d/KE
AWW>/d/KE͗Z/&ZWZD/dREDUCED FARE PERMIT
ůůĂƉƉůŝĐĂŶƚƐŵƵƐƚĐŽŵƉůĞƚĞƚŚŝƐƉĂŐĞ͗
^ƚĂƚƵƐ;ĐŚĞĐŬŽŶĞͿ͗
ƉƉůLJŝŶŐĨŽƌ;ĐŚĞĐŬŽŶĞͿ͗
Ì Ì
ÌEĞǁĂƉƉůŝĐĂŶƚ
ÌZĞŶĞǁĂůͲĂƌĚη͗
;ďĞŐŝŶƐǁŝƚŚĂŽƌ&ŽŶLJŽƵƌĐĂƌĚͿ
ÌZŝĚĞ&ƌĞĞWĞƌŵŝƚ;/ĂŵĞŶƌŽůůĞĚŝŶƚŚĞĞŶĞĮƚĐĐĞƐƐWƌŽŐƌĂŵͿ
ÌZĞĚƵĐĞĚ&ĂƌĞWĞƌŵŝƚ;/ĂŵŶŽƚĞŶƌŽůůĞĚŝŶƚŚĞĞŶĞĮƚĐĐĞƐƐWƌŽŐƌĂŵͿ
WůĞĂƐĞƉƌŝŶƚĐůĞĂƌůLJĂŶĚĐŽŵƉůĞƚĞĂůůŝŶĨŽƌŵĂƟŽŶ͗
>ĞŐĂůEĂŵĞ͗&/Z^d
D͘/͘
>^d
;^h&&/yͿ
ŵĂŝůĚĚƌĞƐƐ͗
DĂŝůŝŶŐĚĚƌĞƐƐ͗;ŝŶĐůƵĚĞĂůůŝŶĨŽƌŵĂƟŽŶƌĞƋƵŝƌĞĚĨŽƌŵĂŝůĚĞůŝǀĞƌLJͿ
^dZdZ^^ŽƌWKKyη͗
/dz͗
ĂƚĞŽĨŝƌƚŚ;ŵŵͬĚĚͬLJLJLJLJͿ͗ ^ŽĐŝĂů^ĞĐƵƌŝƚLJη͗
^dd͗ ͬ ͬ
/WK͗
^ĂŵƉůĞ^ŝnjĞ
Ϯ͟
ͲͲ
dĞůĞƉŚŽŶĞη͗;Ϳ
Ϯ͟
ĞƐƵƌĞƚŽŝŶĐůƵĚĞ>>ŽĨƚŚĞĨŽůůŽǁŝŶŐŝƚĞŵƐ͗
ÌÌϮ͟ďLJϮ͟ĐŽůŽƌƉŚŽƚŽ;ĐůĞĂƌůLJƐŚŽǁƐĨĂĐĞͿ
Ì WƌŽŽĨŽĨĚŝƐĂďŝůŝƚLJ;ĨŽƌWĞƌƐŽŶƐǁŝƚŚŝƐĂďŝůŝƟĞƐZĞĚƵĐĞĚ&ĂƌĞWĞƌŵŝƚͿ
ÌÌůĞĂƌĐŽƉLJŽĨďŽƚŚƐŝĚĞƐŽĨĐƵƌƌĞŶƚŐŽǀĞƌŶŵĞŶƚͲŝƐƐƵĞĚ/ĐĂƌĚ
(Photo)
(Any one of the following: Driver’s License, Passport, State issued ID, U.S.
/ŵŵŝŐƌĂƟŽŶ͕ůŝĞŶƌĞŐŝƐƚƌĂƟŽŶĐĂƌĚ͕ŽƌĂŶLJŽƚŚĞƌŽĸĐŝĂůŐŽǀĞƌŶŵĞŶƚ/
with your picture, date of birth and signature)
ƉƉůŝĐĂƟŽŶŵƵƐƚďĞƐŝŐŶĞĚ͗/ƵŶĚĞƌƐƚĂŶĚƚŚĂƚƚŚĞƉƵƌƉŽƐĞŽĨƚŚŝƐĐĞƌƟĮĐĂƟŽŶŝƐƚŽĚĞƚĞƌŵŝŶĞĞůŝŐŝďŝůŝƚLJĨŽƌƚŚĞZd
ZĞĚƵĐĞĚ&ĂƌĞŽƌZŝĚĞ&ƌĞĞWĞƌŵŝƚWƌŽŐƌĂŵ͕ĂŶĚĂŐƌĞĞƚŽƌĞůĞĂƐĞƚŚĞŝŶĨŽƌŵĂƟŽŶĨƌŽŵƚŚĞ/ůůŝŶŽŝƐĞƉĂƌƚŵĞŶƚŽŶŐŝŶŐ
ĞŶĞĮƚĐĐĞƐƐWƌŽŐƌĂŵĨŽƌƚŚĂƚƉƵƌƉŽƐĞ͘dŚĞŝŶĨŽƌŵĂƟŽŶƌĞƋƵĞƐƚĞĚŽŶƚŚŝƐĂƉƉůŝĐĂƟŽŶŝƐĞdžĞŵƉƚĨƌŽŵƉƵďůŝĐĚŝƐĐůŽƐƵƌĞƚŽ
ƚŚĞĞdžƚĞŶƚƉĞƌŵŝƩĞĚďLJƉĂƌĂŐƌĂƉŚϮϬϳŽĨƚŚĞ/ůůŝŶŽŝƐ&ƌĞĞĚŽŵŽĨ/ŶĨŽƌŵĂƟŽŶĐƚ;ϱ/>^ϭϰϬͬϭd^Y͘Ϳ͘/ƵŶĚĞƌƐƚĂŶĚƚŚĂƚ
ĂŶLJŝŶĨŽƌŵĂƟŽŶĨĂůƐĞůLJƉƌĞƐĞŶƚĞĚŽŶƚŚĞĂƉƉůŝĐĂƟŽŶŵĂLJƌĞƐƵůƚŝŶŵLJƉƌŽƐĞĐƵƟŽŶƚŽƚŚĞĨƵůůĞƐƚĞdžƚĞŶƚĂůůŽǁĂďůĞƵŶĚĞƌƚŚĞ
ůĂǁ͘/ƵŶĚĞƌƐƚĂŶĚƚŚĂƚŝĨ/ĂŵŝƐƐƵĞĚĂŶZdZĞĚƵĐĞĚ&ĂƌĞŽƌZŝĚĞ&ƌĞĞWĞƌŵŝƚƚŚĂƚƚŚĞƉĞƌŵŝƚŝƐĨŽƌŵLJƉĞƌƐŽŶĂů
ƵƐĞŽŶůLJ͕ĂŶĚƚŚĂƚŝĨ/ĂůůŽǁĂŶŽƚŚĞƌƉĞƌƐŽŶƚŽƵƐĞŵLJĐĂƌĚ͕ƚŚĞŶƚŚĞĐĂƌĚĐŽƵůĚďĞƌĞǀŽŬĞĚ͕/ĐŽƵůĚďĞƌĞŵŽǀĞĚĨƌŽŵƚŚĞ
ƉƌŽŐƌĂŵ͕ĂŶĚ/ŵĂLJďĞƉƌŽƐĞĐƵƚĞĚƚŽƚŚĞĨƵůůĞƐƚĞdžƚĞŶƚĂůůŽǁĂďůĞƵŶĚĞƌƚŚĞůĂǁ͘
ĂƚĞ͗
^ŝŐŶĂƚƵƌĞ͗
CENTER USE ONLY
EdZK͗
d<Ez͗(INITIALS)
ϯ
ATTACH HERE
WZ^KE^t/d,/^/>/d/^WZD/dWW>/d/KE
KŶůLJĂƉƉůŝĐĂŶƚƐĂƉƉůLJŝŶŐĨŽƌĂWĞƌƐŽŶƐǁŝƚŚŝƐĂďŝůŝƟĞƐZĞĚƵĐĞĚ&ĂƌĞƉĞƌŵŝƚ͕ƵƐŝŶŐĂĚŽĐƚŽƌ͛ƐƐƚĂƚĞŵĞŶƚ
ĂƐƉƌŽŽĨŽĨĚŝƐĂďŝůŝƚLJ͕ŵƵƐƚĐŽŵƉůĞƚĞƚŚŝƐƉĂŐĞ͗
TO BE COMPLETED BY A LICENSED MEDICAL PROFESSIONAL
ƉƉůŝĐĂŶƚƐĚŽŶŽƚƋƵĂůŝĨLJŝĨƚŚĞŝƌƐŽůĞĐŽŶĚŝƟŽŶŝƐƉƌĞŐŶĂŶĐLJ͕ŽďĞƐŝƚLJ͕ŝŵƉĂŝƌŵĞŶƚĚƵĞƚŽĚƌƵŐƐͬ
ĂůĐŽŚŽůĂďƵƐĞ͕ŽƌĂĚLJƐĨƵŶĐƟŽŶƚŚĂƚĐĂŶďĞĐŽŶƚƌŽůůĞĚƚŚƌŽƵŐŚŵĞĚŝĐĂƟŽŶ͘WůĞĂƐĞĐŚĞĐŬƚŚĞĂƉƉƌŽƉƌŝĂƚĞ
ďŽdž͘ƉƉůŝĐĂŶƚŝƐĞůŝŐŝďůĞĨŽƌĂZĞĚƵĐĞĚ&ĂƌĞWĞƌŵŝƚŝĨŽŶĞŽĨƚŚĞĨŽůůŽǁŝŶŐĐƌŝƚĞƌŝĂůŝƐƚĞĚďĞůŽǁĂƉƉůŝĞƐ͗
ÌƉŚLJƐŝĐĂůĚŝƐĂďŝůŝƚLJ͕ŝŶĐůƵĚŝŶŐďƵƚŶŽƚůŝŵŝƚĞĚ
ƚŽ͗ƌĞƐƉŝƌĂƚŽƌLJ͕ĐĂƌĚŝĂĐ͕ŽƌŶĞƵƌŽůŽŐŝĐĂů
ĚŝƐĂďŝůŝƟĞƐ͕ĂƉĞƌƐŽŶƌĞĐĞŝǀŝŶŐĚŝĂůLJƐŝƐ͕ůŝǀŝŶŐ
ǁŝƚŚ/^͕D^ŽƌĂĐŚƌŽŶŝĐƉƌŽŐƌĞƐƐŝǀĞ
ĚĞďŝůŝƚĂƟŶŐĚŝƐĞĂƐĞ
ÌŶŝŶƚĞůůĞĐƚƵĂůĚŝƐĂďŝůŝƚLJŽƌĚĞǀĞůŽƉŵĞŶƚĂů
ĚŝƐĂďŝůŝƚLJ
ÌƉƐLJĐŚŝĂƚƌŝĐĚŝƐĂďŝůŝƚLJƚŚĂƚŝƐĐŚƌŽŶŝĐŝŶŶĂƚƵƌĞ
WůĞĂƐĞŝŶĚŝĐĂƚĞƚŚĞĚƵƌĂƟŽŶŽĨĚŝƐĂďŝůŝƚLJ͗
ÌÌ 6 mths
Ì ĚŝƐĂďŝůŝƚLJƚŚĂƚĞīĞĐƚƐŵŽďŝůŝƚLJ͕ŝŶĐůƵĚŝŶŐďƵƚnot
ůŝŵŝƚĞĚƚŽ͗ƉĞŽƉůĞǁŚŽĂƌĞŶŽŶͲĂŵďƵůĂƚŽƌLJ͕ƵƐĞ
ĂŵŽďŝůŝƚLJĂŝĚ͕ŚĂǀĞĂƌƚŚƌŝƟƐŽƌĂŶĂŵƉƵƚĂƟŽŶ
ÌϵŵƚŚƐ ÌÌϭLJĞĂƌ ÌÌÌ4 years
ÌÌ ƉƉůŝĐĂŶƚ͛ƐŝŵƉĂŝƌŵĞŶƚĚŽĞƐŶŽƚŵĞĞƚĂŶLJ
ŽĨƚŚĞĨƵŶĐƟŽŶĂůůŝŵŝƚĂƟŽŶƐůŝƐƚĞĚĂďŽǀĞ͘
dŚĞƌĞĨŽƌĞ͕/ĐĂŶŶŽƚĐĞƌƟĨLJƚŚĂƚƚŚĞĂƉƉůŝĐĂŶƚ͛Ɛ
impairment meets the criteria for
ƌĞĐĞŝǀŝŶŐƚŚĞZdZĞĚƵĐĞĚ&ĂƌĞWĞƌŵŝƚĂƚ
ƚŚŝƐƟŵĞ͘
ÌƉĞƌƐŽŶǁŚŽŝƐďůŝŶĚŽƌǀŝƐƵĂůůLJŝŵƉĂŝƌĞĚ
ÌƉĞƌƐŽŶǁŚŽŝƐĚĞĂĨŽƌŚĂƐĂŚĞĂƌŝŶŐĚŝƐĂďŝůŝƚLJ
;ƵĚŝŽůŽŐŝƐƚĂƉƉƌŽǀĂůŽŶůLJͿ
/ĨĂƉƉůŝĐĂŶƚŵĞĞƚƐƚŚĞĞůŝŐŝďŝůŝƚLJĐƌŝƚĞƌŝĂ͕ƉůĞĂƐĞĂƩĂĐŚĂƐƚĂƚĞŵĞŶƚŽŶLJŽƵƌƉƌŽĨĞƐƐŝŽŶĂůůĞƩĞƌŚĞĂĚ
ŽƌƉƌĞƐĐƌŝƉƟŽŶĨŽƌŵ;ƉůĞĂƐĞƚLJƉĞŽƌƉƌŝŶƚͿŶŽƟŶŐƚŚĞĚŝĂŐŶŽƐŝƐŽĨƚŚĞĂƉƉůŝĐĂŶƚĂŶĚĚĞƐĐƌŝďŝŶŐŝŶ
ĚĞƚĂŝůǁŚLJŚĞͬƐŚĞŵĞĞƚƐƚŚĞĞůŝŐŝďŝůŝƚLJĐƌŝƚĞƌŝĂ͘WŚŽƚŽĐŽƉŝĞƐĂŶĚĨŽƌŵůĞƩĞƌƐĂƌĞŶŽƚĂĐĐĞƉƚĂďůĞ͘
dŚŝƐƐƚĂƚĞŵĞŶƚŝƐƌĞƋƵŝƌĞĚŝŶŽƌĚĞƌƚŽƉƌŽĐĞƐƐƚŚŝƐĂƉƉůŝĐĂƟŽŶ͘ŚĞĐŬKŶĞ͗
ÌÌ Physician
ÌÌPsychiatrist
Psychologist
Optometrist
ƵĚŝŽůŽŐŝƐƚ ŚŝƌŽƉƌĂĐƚŽƌ
ÌÌEƵƌƐĞWƌĂĐƟƟŽŶĞƌ
Physician Assistant
ED;W>^WZ/EdͿ͗
h^/E^^Z^^͗
/dz͗ ^dd͗ Wd/Ed͛^ED;W>^WZ/EdͿ͗
͘K͗͘
tZ/dzKhZ>/E^EhDZ͗
ͳ
/WK͗
^dd͗
dŚŝƐŶƵŵďĞƌǁŝůůďĞǀĞƌŝĮĞĚďLJLJŽƵƌ^ƚĂƚĞĞƉĂƌƚŵĞŶƚŽĨWƌŽĨĞƐƐŝŽŶĂůZĞŐƵůĂƟŽŶ͘WůĞĂƐĞŶŽƚĞƚĞŵƉŽƌĂƌLJŶƵŵďĞƌƐĂƌĞŶŽƚĂĐĐĞƉƚĞĚ͘
/ŶĨŽƌŵĂƟŽŶĨĂůƐĞůLJƉƌĞƐĞŶƚĞĚŽŶƚŚŝƐĂƉƉůŝĐĂƟŽŶďLJĂůŝĐĞŶƐĞĚŵĞĚŝĐĂůƉƌŽĨĞƐƐŝŽŶĂůŵĂLJƌĞƐƵůƚŝŶƚŚĞŝƌƉƌŽƐĞĐƵƟŽŶƚŽƚŚĞĨƵůůĞƐƚĞdžƚĞŶƚĂůůŽǁĂďůĞƵŶĚĞƌ
ƚŚĞůĂǁ͘/ŶĂĚĚŝƟŽŶ͕ĂŶLJĨĂůƐŝĮĐĂƟŽŶŽĨŝŶĨŽƌŵĂƟŽŶŽŶƚŚŝƐĨŽƌŵŵĂLJďĞĐŽŶƐŝĚĞƌĞĚŐƌŽƵŶĚƐĨŽƌƌĞǀŽĐĂƟŽŶ͕ƐƵƐƉĞŶƐŝŽŶ͕ƌĞƉƌŝŵĂŶĚŽƌŽƚŚĞƌĚŝƐĐŝƉůŝŶĂƌLJ
ĂĐƟŽŶ͘ZdƌĞƐĞƌǀĞƐƚŚĞƌŝŐŚƚƚŽ;ϭͿĐŽŶƚĂĐƚƚŚĞůŝĐĞŶƐĞĚŵĞĚŝĐĂůƉƌŽĨĞƐƐŝŽŶĂůƚŽǀĞƌŝĨLJƚŚĞŝŶĨŽƌŵĂƟŽŶƉƌŽǀŝĚĞĚ͕;ϮͿŵĂŬĞƚŚĞĮŶĂůĚĞƚĞƌŵŝŶĂƟŽŶƐŽŶĂŶ
ĂƉƉůŝĐĂŶƚ͛ƐĞůŝŐŝďŝůŝƚLJĨŽƌĂZĞĚƵĐĞĚ&ĂƌĞWĞƌŵŝƚĂŶĚ;ϯͿŚĂǀĞĂŶĂƉƉůŝĐĂŶƚƐƵďŵŝƚƚŽĂƐĞĐŽŶĚĞdžĂŵďLJĂůŝĐĞŶƐĞĚŵĞĚŝĐĂůƉƌŽĨĞƐƐŝŽŶĂůƐĞůĞĐƚĞĚďLJƚŚĞZd͘
/ŚĞƌĞďLJĐĞƌƟĨLJƚŽƚŚĞďĞƐƚŽĨŵLJŬŶŽǁůĞĚŐĞƚŚĞŝŶĨŽƌŵĂƟŽŶŽŶƚŚŝƐĂƉƉůŝĐĂƟŽŶĨŽƌŵŝƐƚƌƵĞĂŶĚĐŽƌƌĞĐƚ͘
ĂƚĞ͗
^ŝŐŶĂƚƵƌĞ͗
4