EFTA01130659.pdf

Application for MTA Reduced-Fare MetroCard for Senior Citizens (65 years or older) ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL General Information — If you receive Medicare Benefits based on a Disability, use the application for People with Disabilities. For telephone assistance in completing this application and for answers to questions about it. call 718 330-1234. If you are unable to complete the form yourself, it can be completed by anyone you choose to assist you or you can visit our NYC Transit Reduced Fare Service Center located at 3 Stone Street in downtown Manhattan. Monday to Friday 9 a.m. to 5 p.m. or MetroCard Bus to apply in person. You must bring an official ID with your birth date indicating that you are a Senior Citizen 65 years or older. You do not need this application notorized when you appear in person. A photo will be taken. All information provided by you will be used solely for the purpose of determining your eligibility for the reduced-fare transportation. Every question on this application must be answered. Incomplete applications or applications submitted without photographs and a copy of proof of age 1 1/2" > documentation will be returned to you. Allow two to four weeks for processing. Recent photo must fit in the If you are mailing this application, you must submit a recent photograph. Please write your name on the back of the photograph. The photograph must be at space provided least two inches high and one-and-a-half inches wide (2"x11/2") with a solid background showing a full front view of your face. Please see diagram at left. Request Type New Applicant EasyPay Customer Type or print in ink and sign where indicated. Last Name 111111111111111111111 1I First Name 1 H1 1 H1 !MIMI H1 I M.I. Street Address Apt. No. City/Borough State Zip Code Home Te ephone Work/Other Telephone Date of Birth Your Soc'al Security Number (options) Code Male n Female 1 mta.info 1 0 Metropolitan Transportation Authority EFTA01130659  Please attach proof of age documentation; A photocopy of one of the following is required (check box): Birth Certificate Driver's License Medicare Card OR If you are a Valid State ID Passport Senior Citzen 65 years or older. Applications submitted without copy of proof of age documentation will be returned to you. Notary Public State of ss: County of Must be completed On this thy of 20 before me appeared for all applicants, except when applying in person to me known and known to me to be (Check the one that applies.) with photo ID. the person who is described in and who executed the foregoing instrument the personal representative of the applicant named above and who executed the foregoing instrument on behalf of the applicant. and (s)he duly acknowledged to me that (s)he executed the same and that the statements therein are true. Signature and stamp of officer NOTARY PUBLIC Affirmation I am a senior citizen 65 years or older. I affirm under penalty of perjury that all statements made on this application, which the Metropolitan Transportation Authority relies on to determine my eligibility status, are true and complete. I have read and understand all the information contained in this application. I understand that all statements made in this application may be subject to investigation and verification and that a material misstatement or fraud will disqualify me for reduced-fare privileges. I understand that the MTA may discontinue or change its reduced-fare program without notice. If the MTA should find that I have not followed the Reduced-Fare Program Conditions of Use, I understand that my Reduced-Fare MetroCard will be cancelled and I will not be eligible to reapply for the reduced-fare program. I understand that it is a crime to allow anyone else but me to use the MTA Reduced-Fare MetroCard. By signing this application I (1) acknowledge that I have read the enclosed Conditions of Use for MTA Reduced-Fare MetroCard and (2) accept and agree to be bound by such conditions of use. Applicant's Signature X Date or Personal Representative Date (print name) 2 20/ II EFTA01130660  The EaSyPay Option- Sign up for EasyPay automatic refills (All payment information will be kept strictly confidential.) Start paying for your rides with $10. Your account will be automatically replenished whenever the balance goes below $10. Your account immediately converts to unlimited rides when the required number of subway or local bus rides is taken within a 30-day billing period. Questions? Call 1-877-323-7433 1 I I I I I I I I I I I I I I I I I I I I I IH1 First Name I I I I l l llll l l l l l ll l lll lll l 1 Last Name — I I I ! I I I I -I I I I-I I I I ! Date Of Birth Telephone Home work other Payment Options (choose one) ❑ Credit ❑ Debit Card American Express L Discover MasterCard Visa inn I II I I 'DODD-1OOEO n❑/I I Credit/Debit Card Number Expiration Date I authorize MTA New York City Transit to charge this credit/debit card for my EasyPay MetroCard refills. Signature Date Card holder signature Of different) Applications without Credit/Debit Card authorization signature will be returned to you. I am a visually impaired customer and wish the following statement: (check one) ❑ Large Type ❑ Braille For further information or additional copies of the application, call 718-330-1234. If you are deaf or hard of hearing, use the free 711 relay or your preferred relay service provider to contact us. Or visit mta.info Before Mailing the Application include: Mail completed application to: 1 - A recent photograph Metropolitan Transportation Authority 2 - A copy of proof of age or Medicare Card Reduced-Fare Program 3 — A Notary Public 130 Livingston Street 4 — Affirmation Signature (page 2) Brooklyn, New York 11201-9625 For Office Use Only Disk U Image # Examiner's Signature 3 3 Metropolitan Transportation Authority EFTA01130661 MTA Reduced-Fare MetroCard Conditions of Use and Other Important Information for a Metropolitan Transportation Authority Reduced-Fare MetroCard (RFM) issued to people 65 years of age and older and people with disabilities. This program is managed by MTA New York City Transit. 07 SaditIlf• ORIN (71.1.41.1101 R Valid Use: RFM can be used to pay fares on all MTA The holder assumes the risk of loss until the card is received New York City Transit subways, NYC Transit local buses, by either MetroCard Customer Claims or the MetroCard express buses only during non rush hours, MTA Staten Island Service Center. Railway, Nassau Inter-County Express Bus (NICE), MTA Bus, Roosevelt Island Tram, Westchester Bee-Line local buses and Change of Address: Notices and replacement cards will be express Bee-Line BxM4C buses only during non rush hours. sent to you at the address you provide. You must inform us promptly, in writing, of any change of address. The RFM is valid identification for eligibility in the reduced-fare programs of the MTA Long Island Rail Road and MTA Lost or Stolen RFMs: Immediately report a lost or stolen Metro-North Railroad, anytime except weekday rush hours to RFM by calling the MetroCard Customer Service Center, New York City terminals. To receive the reduced fare, show the 718-330-1234, 6 AM to 10 PM or via our MetroCard eFIX RFM to train personnel or station agents when purchasing system at www.mta.info. Any value or unlimited rides on your ticket. your card will be transferred to your replacement RFM after the old RFM has been frozen and any balances verified. Expiration Dates: Reduced-Fare MetroCards expire on the date printed on the back of the card. As long as you actively Restrictions: An RFM may be used only by the person to use your card, NYC Transit automatically sends you a new whom it has been validly issued. Use of the RFM by any other RFM before the expiration date. person may result in forfeiture of the card and its remaining balances, plus civil and/or criminal penalties. The full value on an expired RFM may be transferred to a new RFM at a subway station booth. Any remaining value that is There are no refunds of money remaining on RFMs. Money not transferred to a new RFM within two years after the remaining on an expired card may only be transferred to a new expiration date on the original RFM will be surrendered by, and card within two years of the expiration date. Money from a full- unavailable to, the card holder. fare MetroCard cannot be transferred to a temporary or permanent RFM. No redemptions or exchanges will be given Trouble Using RFMs: An RFM that does not work or is for an RFM that has been altered or tampered with, or whose damaged should be returned to MetroCard Customer Claims. value cannot be verified. Ask a station booth agent or bus operator for a prepaid envelope in which to return your card to us. In the envelope The City of New York, the State of New York, the County of you'll find a form to fill out so you can describe your RFM Westchester and the Metropolitan Transportation Authority problem. and its subsidiaries and affiliates, including New York City Transit, are not liable for any special or consequential If you prefer, you may bring your damaged RFM to the damages associated with or resulting from the failure, MetroCard Customer Service Center at 3 Stone Street in malfunction, or disabling of the RFM or the MetroCard system. downtown Manhattan, 9 AM to 5 PM, Monday to Friday. The MTA Reduced-Fare MetroCard and its use are If you cannot get a prepaid mailer, send the damaged card to: subject to all tariff provisions, rules and regulations of MetroCard Customer Claims the New York City Transit Authority and its affiliates, and Westchester County Bee-Line System. 130 Livingston Street Brooklyn, New York 11201-9625 Be sure to include your name, address and phone number, your damaged RFM, an explanation of the problem and the address to which the new RFM should be sent. For more information, call 718-330-1234 6 AM to 10 PM. If you are deaf or hard of hearing, use the free 711 relay or your preferred relay service provider to contact us. Have the card at hand so you can read the serial number and expiration date to the customer service agent who assists you. EFTA01130662