Transportation Scholarship Application

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TOWN OF FLOWER MOUND SENIORS IN MOTION TRANSPORTATON SCHOLARSHIP APPLICATION The Town of Flower Mound strives to promote a healthy and active lifestyle for the entire community. Everyone should have the opportunity to participate in fun and outgoing recreational opportunities. For some members of the senior community, the lack of transportation prohibits their ability to enjoy the recreational opportunities offered at the Flower Mound Senior Center. Therefore, the Town of Flower Mound in partnership with SIM Auxiliary, Inc. will be offering a scholarship program for those who need financial assistance paying for transportation to and from the Flower Mound Senior Center. Applications must be filled out completely and returned with all necessary documents to the Flower Mound Senior Center. All applicant information will be reviewed by Senior Center Manager and remain confidential. Applicants must provide updated income and tax documentation on an annual basis to remain eligible for the scholarship. Eligible applicants will be entitled to reimbursement of 80% of the cost of transportation provided by SPAN to and from the Flower Mound Senior Center. Applicants are eligible to receive reimbursement for up to six (6) one way trips (or three (3) round trips) per week. Applicants will be required to pay for the one way rides at the time of service. The Town will receive a monthly usage report from SPAN and reimbursement checks will be issued within 15 days of receipt of the report. Reimbursement checks will be provided by the SIM Auxiliary and mailed to the applicant’s home address. Eligible applicants will also be required to fill out an application with SPAN. Applications can be obtained by visiting www.span-transit.org or calling 940.382.1900. Eligible riders are responsible for scheduling transportation to and from the Senior Center with SPAN. Funds reimbursed through this scholarship program are only to be used for transportation to and from the Senior Center from the applicant’s primary home address. This program is offered by the Town of Flower Mound and is not affiliated with SPAN. All other trips provided though SPAN will not be eligible for reimbursement. CRITERIA: 1.

Must be a resident of Flower Mound and a member of the Seniors In Motion program at the Flower Mound Senior Center. Proof of residency will be verified through a valid driver’s license, utility bill, or lease agreement.


2.

Individuals must be 65 years of age or older and/or have a professionally verified disability.

3.

Must meet income eligibility requirements as shown in the table below. Please provide a copy of your previous year’s tax return (Form 1040) and any associated W-2 forms with this application. Please black out all social security numbers and other personal information. Household Size 1 2 3 4

Annual Household Monthly Household Income Income $23,107 $1,926 $31,284 $2,607 $39,461 $3,289 $47,638 $3,970

*Federal Income Eligibility Guidelines – Effective from July 1, 2019 – June 30, 2020

APPLICATION PROCESS: 1. 2. 3.

Complete attached application form Attach copies of required documentation Return completed application & required documents by mail or in-person to: Senior Center Manager Attn.: Jaime Jaco-Cooper 2701 W. Windsor Drive Flower Mound, TX 75028

For more information or questions regarding eligibility, please contact the Senior Center Manager, Jaime Jaco-Cooper at 972.874.6101 or by email at jaime.jacocooper@flowermound.com.


TRANSPORTATION SCHOLARSHIP APPLICATION APPLICANT INFORMATION NAME: ADDRESS: CITY: ZIP: HOME PHONE: CELL PHONE: EMAIL: DATE OF BIRTH: INCOME INFORMATION TOTAL MONTHLY HOUSEHOLD INCOME: NUMBER OF HOUSEHOLD MEMBERS: TAX FILING STATUS: Single Head of Household Married filing jointly Married filing separately Household Members: Name: __________________________ Name: _________________________ Name: __________________________ Name: _________________________ ACKNOWLEDGMENT: I understand the following rules and responsibilities (please check each box):  Applicant must have a current Seniors In Motion (SIM) membership and be a resident of Flower Mound that is 65 years of age or older.  Applicant must provide copy of the previous year’s tax return with this application.  Senior Center Manager will review and approve application based on income eligibility requirements. All information will remain confidential.  Transportation will only be provided by SPAN.  Applicant must abide by all Town and SPAN rules and regulations.  Reimbursement will only apply for transportation between the Flower Mound Senior Center and the applicant’s primary address.  Applicant is responsible for scheduling transportation to and from the Senior Center.  Applicant is responsible for paying the one way fare to SPAN at the time of service.  Reimburse is limited to 80% of the total cost for a one way fare (limit of six (6) one way trips per week).  Eligible riders will receive a reimbursement check on a monthly basis. Check will be made out to the eligible rider and mailed to the address listed above. Reimbursement checks will be provided by the SIM Auxiliary.  Additional documentation may be required to verify income. I have read and agree to adhere to the above policies. I certify that the information provided in this application is accurate. I understand that false information may result in denial of services. I further understand that all information will be kept confidential, and only the information required to provide the services I request will be disclosed to those involved in the performance of those services.

SIGNATURE:____________________________________DATE:_____________