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Application for an English National Bus Pass* for a DISABLED PERSON
Lincolnshire Concessionary Fare Scheme
If you have any difculties or enquiries regarding this form please telephone 0345 456 4474.
Please read and complete this form carefully in CAPITAL LETTERS and attach your photograph in the space provided.
Section A - Your Details Mark check boxes with a
Title: Mr Mrs Miss Ms Other (please state)
Forename:
Surname:
Date of Birth:
D
Gender: Male
D
M
Y Y
Female
M
Y
Other
Y
Address:
Postcode:
Telephone:
Section B - Your Photograph
Write your name in CAPITAL LETTERS and date of birth on the back of your photograph.
Your photograph must be:
Taken within the last 12 months
Passport size
Colour
Showing your full face without a hat or sunglasses
Section C - Supporting Evidence of Residency and Identity
Remove tab
and attach your
photograph here
Please do not send original documents in the post. Copied documents that you provide may be
electronically saved; hard copy documents will be securely destroyed.
Please submit one document from each list below.
Mandatory Proof of Identity
Passport
Driving Licence
Armed Forces or Police ID
Proof of State Benet or Pension
Mandatory proof of residency
Utility bill
Current Local Council Tax Bill
Bank Statement
Medical Letter
Doctor’s Repeat Prescription
The address on this document must match the
address on the appilcation and must be dated within
the last 6 months (or be your Council Tax Bill for the
current year)
PLEASE CONTINUE OVERLEAF
*
An RFID tag is incorporated within each pass in a bid to reduce fraudulent use.
The details encoded are a unique number, gender, card type, county of issue and expiry date. For further information visit www.lincolnshire.gov.uk/concessionaryfares
Section D - Supporting Evidence of Disability
Please indicate under which categories below you are making your application and provide proof of
eligibility with copies of the documents listed.
Disability
Cross the
relevant
boxes
Examples of acceptable evidence
Blind or partially sighted people
Blind Person’s Registration, or Partially Sighted Registration,
or a letter from an Optometrist conrming eligibility. AFCS*
Deaf people
A hearing loss of 70dBHL or greater. A signed statement
from an audiologist or aural specialist about your level of
hearing loss. AFCS*
People without speech
Letter from a Doctor conrming that you are unable to
communicate orally in any language or Personal Independent
Payment (PIP) with 8 points or more for the Communicating
Verbally activity. AFCS*
People with ‘substantial and
long-term walking difculties’
High Rate mobility component of Disability Living Allowance
(DLA) in payment, or PIP with 8 points or more for the Moving
Around activity; or a disabled persons parking badge (blue
badge), or war pensioner’s mobility supplement, or a letter
from your Occupational Therapist conrming you can only
walk with ‘excessive labour at an extremely slow pace or with
excessive pain’. AFCS*
Do you have an LCC issued Blue Badge? Yes No
People with no arms or loss of
use of both arms
Letter from a Doctor conrming your disability. If there is
doubt, medical opinion should be sought. AFCS*
People with a Learning Disability
causing signicant impairment of
intelligence or social functioning
Learning disability that has started before adulthood. Higher
rate DLA or PIP at 8 points or more in the Communicating
Verbally activity. Letter from your consultant, social worker or
head teacher conrming that your learning disability meets the
eligibility criteria.
Persons refused a driving licence
on medical grounds other than
drug/ alcohol abuse
Refusal letter from DVLA or a letter from your GP if you
have not applied for a licence but would be refused on
medical grounds if you did. AFCS*
AFCS*: Payment for injury under tariffs 1-8 of the Armed Forces Compensation Scheme may also be
considered as acceptable evidence when relevant to this criteria.
Section E - Declaration
I certify that the address stated is my permanent residence and I am entitled to the concession applied
for on the basis of the disability shown. I agree to Lincolnshire County Council (LCC) making any enquiries
it considers necessary to check the information provided. I will notify LCC if I move house and provide
proof I live at that address or return my bus pass if I move out of Lincolnshire. I understand if lost or
damaged, there will be a £10 charge for a replacement pass. (LCC follows best practice in managing
personal information with other authorised bodies for the purposes of administering the scheme. Refer to
our Privacy Notice at www.lincolnshire.gov.uk/concessionaryfares for more information or call to request
a paper version.) I accept that it may use or share my information with other authorised bodies for the
purposes of administering the scheme, issuing the travel pass, auditing or fraud prevention.
Signed
Date
D MD Y YM
Completed Application Forms
Please send completed application forms and photocopies of documents to:
Concessionary Fares Team, PO BOX 1305, Lincoln, LN5 5RT
Alternatively you can complete and scan this form, together with your documents and photo and email
to: concessionaryfares@lincolnshire.gov.uk
For Ofce Use Only
Proof of identity
Proof of residency Signature / Initials
Proof of disability Date:
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