Low-Income Fare is Easy (LIFE) Program Request Frequent Use: TAP CARD You must provide proof of Medical. First Name and Middle Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birth Date (mm/dd/yyyy) * MM DD YYYY Email * Telephone Number * (###) ### #### Gender * Female Male Other Ethnicity * Asian Or Pacific Islander Black Hispanic Native American White Prefer not to answer ID Number * Do you receive any of the following? * Medi-Cal EBT Social Security Income Government or public benefits I will qualify by providing my check stub or tax return MediCal Plan * Health Net LA Care Molina Blue Shield Blue Cross Aetna Kaiser Regular Medical Other MediCal Number * As head of household participating in the Low-Income Fare is Easy (LIFE) Program, I affirm that I am 18 years or older and that the information provided on this application for myself and my household, including the annual household income, is true and correct. I understand that the LIFE Program reserves the right to verify my household income, and I will notify the LIFE Program if I or any household member no longer qualifies for the LIFE discount. I acknowledge that neither I nor any household member is participating in the LIFE Program under a different name. I also understand that neither I nor any household member can be part of any other program that discounts passes including, but not limited to, Access Paratransit, City Ride, and/or other transportation discount programs. I understand that my first name, last name, address, phone number, email address, birthday, gender, income bracket and number of household members will securely be stored in the LIFE database and only accessed by participating LIFE agencies By failing to adhere to the above terms and conditions, I or any household member will be disqualified from participating in the LIFE Program. * By checking this box, I hereby agree to receive communication regarding My New House and Metro products or services. Dear Applicant,Thank you for submitting your application for the LIFE Program. We truly appreciate your interest and engagement.Please anticipate the arrival of your TAP Card by mail within the next 7 to 10 days. This card will be your key to accessing the benefits of the LIFE Program.Additionally, you will receive a confirmation email from Metro, providing further details about your application status.Feel free to contact us at life@mynewhousela.org if you have any questions or need further assistance. We are here to help and support you.Sincerely,My New House
