If you wish to receive transportation assistance through the transportation disadvantaged program, you must complete this form in full.

Name: 
Address: 
City:
State:
Zip:
Home or Message Phone: 
Date of Birth:
Do you have the use of an automobile?
Do you have any friends or family who can take you to obtain goods and services as necessary?: 
If the above answer is no please explain how you were getting around previously
Can you use public transport (public bus) to get where you need to go?  
If the above answer is no please explain
Are you presently enrolled in any Government assistance programs, such as AFDC, Food Stamps, Medicaid, JTPS or County Social Services?
If the answer to the above question is Yes, please list the program(s) you are in and your ID number.
Do you have any physical or mental disabilities?
If the answer to the above question is Yes, please describe them.
How many times during a typical month do you expect to need transportation? (The number of trips you expect to make in a months time)
What kind of trips do you expect to need? (to medical/dental appointment, pharmacy, banks, social security offices, human services offices, grocery, employment, etc.):

Enter your social security number here:


How many persons are in your household? Please list ALL persons in your household, their relationship to you, AND their SOCIAL SECURITY NUMBER. Include ALL immediate family members (YOURSELF, spouse, mother, father, sons, daughters, stepchildren, brothers, sisters, grandparents and grandchildren living at the same address)
What is your current household monthly gross (before tax) income?
Please list all sources of income, such as employment, Social Security, interest or any other sources of income)
Does anyone in your household require a wheelchair?




Instead of submitting this form online, you may print out a Word document or Adobe PDF document and return by mail to:

GPTMS
13825 Icot Blvd #613
Clearwater, FL 33760

By submitting this form, you are stating that the information you have given is true and complete to the best of your knowledge.