Emergency Ride Form

Please Read First

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.

Name:*

First Last

Date of Ride:*

Phone:*

Email:*

Employer*

Employer Address:*

Street Address City State ZIP Code

Employer Contact Name (if needed for verification)

First Last

Employer Email (if needed for verification)

Enter Email Confirm Email

How you got to work or school on the day ERH was used:*

Bus
Carpool
Ferry
Vanpool
Walk
Bicycle
Train
Other

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

Reason for Emergency Ride Home:*

Personal Illness/Unexpected Emergency
Bicycle Problem
Carpool/Vanpool Problem
Unscheduled Overtime
Family Member Illness/Unexpected Emergency

Type of ride home taken:*

Taxi
Uber/Lyft
Train
Bus

Starting/pick-up address:*

Street Address City State ZIP Code

Destination/drop-off address:*

Street Address City State ZIP Code

Total Costs (upload receipts below):*

Upload your receipts here:

Max. file size: 50 MB.

Address where you would like reimbursement to be sent to:*

Street Address Address Line 2 City State ZIP Code

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

CAPTCHA

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.

Comments

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Marin Emergency Ride Home Reimbursement Request

Please Read First

Finally,