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Part 6. Verification of Income

This section to be completed only if applying for Transportation Disadvantaged (TD) or County Senior Transportation Service (CSTS)

TO BECOME ELIGIBLE FOR THE PROGRAMS MENTIONED ABOVE, YOU MUST ATTACH PROOF OF YOUR INCOME (ALL SOURCES)AS SHOWN BELOW:

Wages and Tips

$

Social Security, SSI, Wages, etc.

$

Pension

$

Other

$

TOTAL HOUSEHOLD INCOME

$ $

SOURCE

AMOUNT (BEFORE TAXES OR DEDUCTIONS)

THIS CONCLUDES THE PORTION OF THE FORM TO BE COMPLETED BY THE APPLICANT.

THE LAST SECTION (PAGE 9 OF THIS APPLICATION MUST BE COMPLETED AND SIGNED BY A LICENSED PHYSICIAN.)

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