Application for CATS Elderly & Disabled Identification Card

E-Mail Address

Applicant Information

Full Name

(First)

(Last)

Date

Mailing Address (include street, city, state and zip code)

Check the appropriate category for the Elderly and/or Disabled ID Card application.

The categories (1-5) below require a State-Issued photo identification to prove participation in and/or eligibility for the programs listed if the documentation does not include a pre-printed photo:

Category

Medicare Identification Card (White card with red and blue stripes)

Department of Motor Vehicles (DMV) Disabled Person placard

Braille Institute Identification Card

SSI Disability Current Year Award Letter (Social Security Income)

Physician’s Assessment/Statement

Elderly & Disabled identification card customer agreement

Each of the below statements must be answered and are required fields to submit this application.

I certify that the information I provided is true and that providing any false information will lead to my card privileges being revoked.

yes

I understand that I must produce this card as identification at all times and upon request.

yes

I understand that only one (1) card will be issued at no cost, and that a replacement card (lost, stolen, or damaged) will cost $8.00.

yes

I understand that no exceptions will be applied to this agreement.

yes