Fare Assistance Program Application Fare Assistance Program Name: Year of Birth: Address: Town/City: Postal Code: Phone number: # People in Household: Email address: What is your yearly household income? (please include all sources): Why are you applying for the Fare Assistance Program? (This information is used to determine financial assistance): I certify that the information I have provided on this application is true and accurate . I understand that East Hants & Area Community Rider reserves the right to request more information and supporting documents, and to provide or deny subsidy at their discretion based on current policies and funds available. I accept these conditions: Date:
