Union County, Ohio - UCBDD Referral- Disability Form (Electronic)

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UCBDD Referral- Disability Form (Electronic)

Union County Agency Transportation Service (UCATS) is offering free fare for riders who are disabled. Funding for these fares is through the Ohio Department of Transportation grant for Specialized Transportation (Section 5310).

UCATS is solely responsible for approval or rejection of applications for eligibility based on program criteria. Appeals may be made to the Union County Human Services at 937-644-1010 extension 2237 or email janell.alexander@jfs.ohio.gov.

Completed application, verification of eligibility or requests for assistance in completing this application should be addressed to UCATS, Suite 1800, 940 London Avenue, Marysville Ohio 43040, or emailed to UCATS’ email address: ucats@unioncountyohio.gov. UCATS can also be reached at: (937) 642-5100.

Please fill out the below information for our files:

Client Information-

*Client's Name:

*Client's Home/Pickup Address:

*Client's Alternate Home/Pickup Address:

*Client's Phone Number:

*Client's Date of Birth:

Emergency Contact Information-

*Emergency Contact Name:

*Emergency Contact Phone Number:

*Emergency Contact Email:

*Service Consultant Signature:

*Date of signature:

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