Revised Sept. 13, 2019 Page 1 of 3
Reduced Transit Fare Identification Card for
Persons with Disabilities Application
This information is confidential and will not be released by the City of Annapolis Department of Transportation.
Applicants full name
Mail address
City ST Zip
Phone(s)
Gender Male Female Date of Birth
Signature Date
To be completed by Physician / Service Professional (please print or type)
I certify that the above named individual qualifies for a disability Reduced Fare Transit Identification Card because:
(please check as many reasons as are applicable. For further explanation, please see page 3):
The person cannot negotiate stairs with ease, reasonable speed, and/or without aid from another person.
The person cannot board or leave a transit vehicle with ease, reasonable speed, and/or without aid from another
person.
The person cannot stand without major support in a moving vehicle operating under normal acceleration and
deceleration.
Due to uncorrectable visual impairment the person cannot read transit vehicle identifications or identify transit
stops.
Due to uncorrectable hearing impairment, the person cannot hear verbal announcements or transit information
through either direct personal or electronic communication.
The individual needs (for valid medical reasons) the aid of a cane, crutches, or other mechanical device to assist
him or her in moving about.
Due to physical or mental conditions, the person cannot use public transit without the help of another person or
special training.
The person's disability can generally be described as:
City of Annapolis
Transportation Department
308 Chinquapin Round Road
Annapolis, MD 21401-4007
Transit@annapolis.gov • 410-263-7964410-269-0674 • Fax 410-269-5989 • TDD use MD Relay or 711 www.annapolis.gov
Revised Sept. 13, 2019 Page 2 of 3
What is the expected duration of the disability?
The disability is permanent (will last longer than twelve months).
The disability is temporary and can be expected to last until: Month __________ Year _________
Certification
Due to the disability indicated above, I hereby certify that the above named applicant is unable to utilize mass transit
facilities and services as effectively as persons who are not so affected, and to the best of my knowledge the above
information is true and correct.
Name of physician License No
Mail address
City ST Zip
Physician Signature Date
Please send the completed form to:
Annapolis Transit Reduced Fare Program, 308 Chinquapin Round Road, Annapolis, MD 21401
FOR CITY USE ONLY
Approved Denied
Signature Date
Revised Sept. 13, 2019 Page 3 of 3
DEFINITION OF FUNCTIONAL IMPAIRMENTS FOR REDUCED TRANSIT FARE PROGRAM FOR PERSONS WITH
DISABILITIES
This Program is required by Section 5 of the Urban Mass Transportation Act of 1964, as Amended
1. The person possesses a Medicare Card and is under 65 years of age.
Any person who qualifies for Medicare need not have this form certified by a physician or social service agency, but
may obtain a card from the transit agency directly upon presentation of his or her Medicare Card. A person over 65
years of age qualifies under Pennsylvania's Free Transit Program for Senior Citizens.
2. The person cannot negotiate a flight of stairs or escalator with ease, reasonable speed and/ or without aid from another
person.
3. The person cannot board or leave a transit vehicle with ease, reasonable speed, and/or without aid from another
person. Standards 2 and 3 have to do with the person's walking and step climbing ability as it relates to the use of rapid
transit systems, buses or trolleys. In order to meet either of these standards the person should have significant difficulty
in:
a. Climbing steps with risers 7 inches or more in height.
b. Negotiating a long flight of stairs.
c. Climbing from ground to first step on the transit vehicle, a distance of approximately 14 inches.
Examples of typical ailments which may qualify under these standards:
a. Amputation of or anatomical deformity of foot or leg.
b. Major restrictions in the movement of joints in hips, back, knee or ankle.
c. Fracture of femur, tibia, tarsal bone or pelvis.
d. Disorders of the nervous system resulting in moderate motor weakness in two extremities.
4. The person cannot stand without major support in a moving vehicle operating under normal vehicle acceleration and
deceleration conditions.
This standard is based on the person's inability to stand in a moving bus, trolley, train or subway car even with the aid
(by holding with the hand) of a stanchion or overhead rail.
Examples of typical ailments which may qualify under this standard:
a. Loss of balance due to inner-ear disorders.
b. Disorders of the nervous system resulting in moderate motor weakness in two extremities.
c. Disorders of the nervous system resulting in moderate lack of coordination of motor functions.
d. Amputation of or major anatomical deformity of foot, leg, arm or hand.
e. Fracture of femur, tibia, tarsal bone or pelvis.
5. Due to uncorrectable visual impairment the person cannot easily read transit vehicle identifications or identify transit
stops. This standard automatically applies if the visual efficiency of the better eye after best correction is 20% or less.
(The percent of remaining visual efficiency equals the product of the percent of remaining central visual efficiency and
the percent of remaining visual field efficiency).
6. Due to an uncorrectable hearing impairment; the person cannot hear verbal announcements or transit information
through either direct personal or electronic communication. This standard applies if manifested by:
a. Absence of air and bone conduction in both ears (auditory perception of not more than one pure tone at high
volume will be considered as absence of air and bone construction); or
b. No more than 40 percent discrimination for speech (ability to hear and understand no more than 40 out of 100
words of special test lists of words using a speech audiometer or hearing aid).
7. The individual needs (for valid medical reasons) the aid of a cane, crutches, or other mechanical device to assist him or
her in moving about.
This standard would include individuals utilizing wheelchairs, long leg braces or other orthopedic appliances which are
needed for medically valid reasons.
8. Due to physical or mental conditions the person cannot use public transit without the help of another person or special
training. The person's need for the aid of another person or training under this standard may be for physical aid and
support or guidance. Organic brain syndrome, functional disorders, or mental deficiencies resulting in severe mental
and social incapacity as evidenced by marked dependence upon others for personal needs or to avoid physical danger
or the inability to understand the spoken word or the inability to follow simple directions would meet this standard. An IQ
of 49 or less automatically qualifies the individual.
Special training includes formal or informal training to help the individual find transit stops or stations, to help in boarding
the vehicle, to relieve unreasonable fears or anxieties or to reduce the probability of violence.
NOTE: If a person with a disability requires assistance from another person, that individual must pay the regular fare. The transit
vehicle operator cannot be expected to assist the person with a disability.
EXCEPTIONS:
1. Disabilities or mobility limitations due solely to pregnancy, obesity, or an alcoholic or illegal drug related problem, are
not considered to be eligible disabilities for the purposes of this program.
2. Persons whose disability is of such a nature that it is likely to prove hazardous to himself, fellow passengers for the safe
operation of the vehicle under normal operating conditions should not be encouraged to use mass transit. Contact your
transit operator for organizations who provide transportation for special needs.
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