Discounted Fare Certification Form

INSTRUCTIONS - This is a written statement from the applicant documenting “Annual (Gross) Income”, the number of members in the household, age, and the income for each member. Annual Gross Income is income from all sources before any deductions, taxes, etc. for a 12-month period. Each adult household member must then sign this statement to certify that the information is complete and accurate, and that source documentation will be provided upon request.

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of assistance. The information provided is subject to verification by the county or eligible municipality.