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Please fill out this form in its entirety. A person age 60 or above and/or a person on disability may apply for this program. If you are applying by age, you must submit a copy of your picture ID for age verification. If you are applying by disability, you must submit a copy of your disability letter for verification. Any applications sent with out a picture ID/Disability letter WILL NOT be processed until your picture ID/Disability letter is received.
A copy of your picture ID or Disability Letter must be submitted or your application will not be processed
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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