Marin Emergency Ride Home Reimbursement Request Digital Signature Form Please Read FirstPlease 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:* Date Format: MM slash DD slash YYYY Phone:*Email:* Employer*Employer Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Destination/drop-off address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total Costs (upload receipts below):*Upload your receipts here:Address where you would like reimbursement to be sent to:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I AGREE TO THE EMERGENCY RIDE HOME PROGRAM RULES, which is available at https://www.tam.ca.gov/wp-content/uploads/2017/12/Final-ERH-Program-Rules-with-Liabilty-Waiver-and-Assumption-of-Risk-12.12.17.pdfSignatureCAPTCHAFinally,Please submit a completed Reimbursement Request form and receipt(s) documenting the emergency ride home to Marinerh@tam.ca.gov or mail all documents to the following address: Transportation Authority of Marin ERH Program, 900 5th Avenue, Suite 100, San Rafael, CA 94901.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
