Emergency Ride Form

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Please complete this form and submit it with receipts within 30 days from the date of the trip. Only trips that are in compliance with the ERH Program Rules are eligible for reimbursement.

Date of Ride:*

Phone:*

Email:*

Employer*

Please describe other reason for how you got to work or school:

Total Costs (upload receipts below):*

Upload your receipts here:

Max. file size: 50 MB.

I AGREE TO THE EMERGENCY RIDE HOME PROGRAM RULES, which is available at http://www.tam.ca.gov/wp-content/uploads/2017/12/Final-ERH-Program-Rules-with-Liabilty-Waiver-and-Assumption-of-Risk-12.12.17.pdf

Signature

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Finally,

Please submit a completed Reimbursement Request form and receipt(s) documenting the emergency ride home to [email protected] or mail all documents to the following address: Transportation Authority of Marin ERH Program, 900 5th Avenue, Suite 100, San Rafael, CA 94901.

Name

This field is for validation purposes and should be left unchanged.

Marin Emergency Ride Home Reimbursement Request

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Finally,

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