Lifeline Voucher Application

Lifeline Mobility Voucher Program

2025 Client Application
GENERAL INFORMATION
Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address -or- Experiencing Homelessness

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email Address
ELIGIBILITY QUESTIONS
How many people live in your household?*
What is your household's monthly income?*
Explain the financial need for the program if you exceed the listed income qualification:*
Separate miles are awarded to each qualified household member. Provide information for each person being considered for the program. For additional household members write their information on a separate sheet.
Household Member 1
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Briefly describe any disabilities and the duration (if applicable):*

Household Member 2
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Briefly describe any disabilities and the duration (if applicable):
Household Member 3
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Briefly describe any disabilities and the duration (if applicable):
Household Member 4
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Briefly describe any disabilities and the duration (if applicable):

Trip Eligibility Information

Fill in the following details for program-eligible trips you usually take each month. Public transportation cannot be available due to hours of operation or lack based on participant location or destination for a trip to qualify. Additional trip information can be emailed to jennyr@brag.utah.gov if more than six are needed.
Name*
Trip Purpose*
Write a short 1-5 word description of the trip purpose.
Destination City*
List the destination city for the trip.
Number of Trips per Month*
Average number of times this sort of trip is taken.
Round Trip Mileage*
Number of miles to and from the destination.
Name
Trip Purpose
Enter a short 1-5 word description of the trip.
Destination City
List the destination city for the trip.
Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Name
Trip Purpose
Enter a short 1-5 word description of the trip.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Name
Trip Purpose
Enter a short 1-5 word description of the trip.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Name
Trip Purpose
Enter a short 1-5 word description of the trip.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.
Name
Trip Purpose
Enter a short 1-5 word description of the trip.
Destination City
List the destination city for the trip.
Number of Trips per Month
Average number of times this sort of trip is taken.
Round Trip Mileage
Number of miles to and from the destination.

VERIFICATION DOCUMENT

Attach valid documentation verifying low income, disability, or senior status below.
File Upload*

Cancelof
I have read the Lifeline Mobility Program information and understand BRAG is not responsible for reimbursements that do not meet the program guidelines or if fraud is suspected. I have attached a valid document verifying low income, disability, or senior status application. I verify that the information I have provided on this form and my income verification is accurate. I agree to update BRAG with any changes to this information and provide accurate information when submitting vouchers. I understand failure to do so may result in being removed from the program or legal action.
Applicant Signature*

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Date

MonthDayYear

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Lifeline Mobility Voucher Program

GENERAL INFORMATION

ELIGIBILITY QUESTIONS

Separate miles are awarded to each qualified household member. Provide information for each person being considered for the program. For additional household members write their information on a separate sheet.

Household Member 1

Household Member 2

Household Member 3

Household Member 4

Trip Eligibility Information

VERIFICATION DOCUMENT