GUARANTEED RIDE HOME
REIMBURSEMENT FORM
We hope that CDTC's Guaranteed Ride Home Program has
assisted you with your unexpected travel
needs. Completion of this form and verification by your
employer/supervisor will insure that your
taxi fare will be reimbursed (up to the cost of the taxi fare minus a
$2.00 co-pay, maximum
reimbursable amount $50.00)
1. Your name and address:
Name:____________________________
Street:____________________________
City/Zip:__________________________
2. Name and address of your employer:
Name:____________________________
Street:____________________________
City/Zip:__________________________
3. Name, title and telephone number of your supervisor?
Name:____________________________
Title:_____________________________
Telephone:_________________________
4. Date of guaranteed ride home:
_______________________________
5. Have you used CDTC's Guaranteed Ride Home service before?
YES_____ NO_____
If"YES", date(S) of prior usage______
_______________________________
_______________________________
6. How do you regularly commute to work?
____Carpool
____Ride the bus
____Walk or Bike
(Note: "regularly means three or more times per week, on
average) |
7. If you regularly carpool or
take the bus, please identify the name and phone numbers of your
carpool partners or the bus company and route:___
___________________________________________
___________________________________________
___________________________________________
8. For what reason did you need this guaranteed ride home?
____My illness
____Family illness
____Unscheduled Overtime
____Carpool partner had emergency
____Other (please explain)______________________
___________________________________________
9. To what location did you take this
guaranteed ride home?
___________________________________________
___________________________________________
10. What taxi company did you use for
your guaranteed ride home and what was the fare? (please attach
receipt)
company___________________________________
fare_______________________________________
11. What is the name and telephone
number of the person who can verify your trip? (This should be a
supervisor, personnel officer, employee relations employee, etc)
__________________________________________
__________________________________________
__________________________________________
|
I affirm that the information I supplied above is
true.
__________________________________________________
participant |
__________________________________
date |
I affirm that the information is true--that the person
requesting reimbursement for this ride home
under the guaranteed ride home program needed the guaranteed ride home
for unplanned overtime
or an emergency and that this person regularly carpools, rides the bus,
bicycles or walks to work
(or any combination thereof).
__________________________________________________
supervisor, personnel director, etc. |
__________________________________
date |
Mail completed form to: Capital District
Transportation Committee, 1 Park Place Main Floor, Albany, NY 12205
|