Application for MTA Reduced-Fare MetroCard for

Senior Citizens (65 years or older)

ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL

General Information — If you receive Medicare Benefits based on a Disability,

use the application for People with Disabilities.
For telephone assistance in completing this application and for answers to questions
about it, call 718 330-1234. If you are unable to complete the form yourself, it can be
completed by anyone you choose to assist you or you can visit our NYC Transit Reduced
Fare Service Center located at 3 Stone Street in downtown Manhattan, Monday to Friday
9 a.m. to 5 p.m. or MetroCard Bus to apply in person. You must bring an official ID with
your birth date indicating that you are a Senior Citizen 65 years or older. You do not need
2"
this application notorized when you appear in person. A photo will be taken.
All information provided by you will be used solely for the purpose of determining your
eligibility for the reduced-fare transportation.
Every question on this application must be answered. Incomplete applications or
applications submitted without photographs and a copy of proof of age
1 1/2" documentation will be returned to you.
Allow two to four weeks for processing.
Recent photo
must fit in the If you are mailing this application, you must submit a recent photograph.
Please write your name on the back of the photograph. The photograph must be at
space provided least two inches high and one-and-a-half inches wide (2"x 1 1/2") with a solid background
showing a full front view of your face. Please see diagram at left.

Request Type n New Applicant n EasyPay

Customer Type or print in ink and sign where indicated.

Last Name

First Name M.I.

Street Address Apt. No.

City/Borough State Zip Code

– – – –
Home Telephone Work/Other Telephone

– – – – –
Date of Birth Your Social Security Number (optional) Code Male Female Unspecified

[Link] mta
 Please attach proof of age documentation;
A photocopy of one of the following is required (check box):
n Birth Certificate n Driver’s License n Medicare Card
n Valid State ID n Passport OR If you are a
Senior Citizen
65 years or older.

Applications submitted without copy of proof of age documentation will be returned to you.

Notary Public State of __________________________________________________ }

ss :
County of _________________________________________________ }

Must be completed On this ______________ day of _______________, 20 ________ before me appeared

for all applicants, _____________________________________________________________________________
except when to me known and known to me to be (Check the one that applies.)
applying in person
with photo ID.
n the person who is described in and who executed the foregoing instrument
n the personal representative of the applicant named above and who executed the
foregoing instrument on behalf of the applicant.
and (s)he duly acknowledged to me that (s)he executed the same and that the
statements therein are true.

Signature and stamp of officer _________________________________________

NOTARY PUBLIC
Affirmation
I am a senior citizen 65 years or older. I affirm under penalty of perjury that all statements made on
this application, which the Metropolitan Transportation Authority relies on to determine my eligibility
status, are true and complete. I have read and understand all the information contained in this
application. I understand that all statements made in this application may be subject to investigation
and verification and that a material misstatement or fraud will disqualify me for reduced-fare
privileges.
I understand that the MTA may discontinue or change its reduced-fare program without notice.
If the MTA should find that I have not followed the Reduced-Fare Program Conditions of Use,
I understand that my Reduced-Fare MetroCard will be cancelled and I will not be eligible to reapply
for the reduced-fare program.
I understand that it is a crime to allow anyone else but me to use the MTA Reduced-Fare MetroCard.
By signing this application I (1) acknowledge that I have read the enclosed Conditions of Use for MTA
Reduced-Fare MetroCard and (2) accept and agree to be bound by such conditions of use.
Applicant’s
Signature X ____________________________________________________________ Date ________________
or Personal Representative ________________________________________________ Date ________________
(print name)
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158_18, Revised May 2018

 The EasyPay Option–Sign up for EasyPay automatic refills
(All payment information will be kept strictly confidential.)
Start paying for your rides with $10. Your account will be automatically replenished whenever the
balance goes below $10. Your account immediately converts to unlimited rides when the required
number of subway or local bus rides is taken within a 30-day billing period.
Questions? Call 1-877-323-7433

nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
First Name

nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Last Name

nn – nn – nnnn nnn – nnn – nnnn

Date Of Birth Telephone n Home n work n other
Payment Options (choose one) o Credit o Debit Card
n American Express n Discover n MasterCard n Visa
nnnnnnnnnnnnnnnn nn / nn
Credit/Debit Card Number Expiration Date
I authorize MTA New York City Transit to charge this credit/debit card for my EasyPay MetroCard refills.

Signature Date

Card holder signature (if different)

Applications without Credit/Debit Card authorization signature will be returned to you.

I am a visually impaired customer and wish the following statement:

(check one) o Large Type o Braille
For further information or additional copies of the application, call 718-330-1234. If you are
deaf or hard of hearing, use the free 711 relay or your preferred relay service provider to
contact us. Or visit [Link]

Before Mailing the Application include: Mail completed application to:

1 – A recent photograph Metropolitan Transportation Authority
2 – A copy of proof of age or Medicare Card Reduced-Fare Program
3 – A Notary Public 130 Livingston Street
4 – Affirmation Signature (page 2) Brooklyn, New York 11201-9625

For Office Use Only

Disk # ________________________________________________________________ Image # _____________________________________

Examiner’s Signature _______________________________________________________________________________________________

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MTA Reduced-Fare MetroCard
Conditions of Use and Other Important Information
for a Metropolitan Transportation Authority Reduced-Fare MetroCard (RFM)
issued to people 65 years of age and older and people with disabilities.
This program is managed by MTA New York City Transit.

Valid Use: RFM can be used to pay fares on all MTA The holder assumes the risk of loss until the card is received
New York City Transit subways, NYC Transit local buses, by either MetroCard Customer Claims or the MetroCard
express buses only during non rush hours, MTA Staten Island Service Center.
Railway, Nassau Inter-County Express Bus (NICE), MTA Bus,
Roosevelt Island Tram, Westchester Bee-Line local buses and Change of Address: Notices and replacement cards will be
express Bee-Line BxM4C buses only during non rush hours. sent to you at the address you provide. You must inform us
promptly, in writing, of any change of address.
The RFM is valid identification for eligibility in the reduced-
fare programs of the MTA Long Island Rail Road and MTA Lost or Stolen RFMs: Immediately report a lost or stolen
Metro-North Railroad, anytime except weekday rush hours RFM by calling the MetroCard Customer Service Center,
to New York City terminals. To receive the reduced fare, 718-330-1234, 6 AM to 10 PM or via our MetroCard eFIX
show the RFM to train personnel or station agents when system at [Link]. Any value or unlimited rides on
purchasing your ticket. your card will be transferred to your replacement RFM after
the old RFM has been frozen and any balances verified.
Expiration Dates: Reduced-Fare MetroCards expire on the
date printed on the back of the card. As long as you actively Restrictions: An RFM may be used only by the person to
use your card, NYC Transit automatically sends you a new whom it has been validly issued. Use of the RFM by any other
RFM before the expiration date. person may result in forfeiture of the card and its remaining
balances, plus civil and/or criminal penalties.
The full value on an expired RFM may be transferred to a new
RFM at a subway station booth. Any remaining value that is You must present your Reduced-Fare MetroCard to a police
not transferred to a new RFM within two years after the officer or transit personnel upon request.
expiration date on the original RFM will be surrendered by,
and unavailable to, the card holder. There are no refunds of money remaining on RFMs. Money
remaining on an expired card may only be transferred to a
Trouble Using RFMs: An RFM that does not work or is new card within two years of the expiration date. Money from
damaged should be returned to MetroCard Customer a full-fare MetroCard cannot be transferred to a temporary or
Claims. Ask a station booth agent or bus operator for a permanent RFM. No redemptions or exchanges will be given
prepaid envelope in which to return your card to us. In the for an RFM that has been altered or tampered with, or whose
envelope you’ll find a form to fill out so you can describe your value cannot be verified.
RFM problem.
The City of New York, the State of New York, the County of
If you prefer, you may bring your damaged RFM to the Westchester and the Metropolitan Transportation Authority
MetroCard Customer Service Center at 3 Stone Street in and its subsidiaries and affiliates, including New York City
downtown Manhattan, 9 AM to 5 PM, Monday to Friday. Transit, are not liable for any special or consequential
If you cannot get a prepaid mailer, send the damaged card to damages associated with or resulting from the failure,
our mailing address at: malfunction, or disabling of the RFM or the MetroCard system.

MetroCard Customer Claims The MTA Reduced-Fare MetroCard and its use are
130 Livingston Street subject to all tariff provisions, rules and regulations of
Brooklyn, New York 11201-9625 the New York City Transit Authority and its affiliates, and
Westchester County Bee-Line System.
Be sure to include your name, address and phone number,
your damaged RFM, an explanation of the problem and the
address to which the new RFM should be sent.

For more information, call 718-330-1234 6 AM to 10 PM. If you are deaf or hard of hearing, use the free 711
relay or your preferred relay service provider to contact us. Have the card at hand so you can read the serial
number and expiration date to the customer service agent who assists you.
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158_18_Sen Appl., Revised May 2018 mta