Emergency Ride Home | Delaware Valley Regional Planning Commission

Use this form to apply for reimbursement for your Emergency Ride Home (ERH). Remember, you must be pre-registered for the Emergency Ride Home Program before your ride home is used. This reimbursement application must be accompanied by a valid ride receipt and must be submitted within 30 days of the ERH. Allow 45 days from receipt of this form for review and reimbursement; reimbursement will be sent in the form of a check. You may only be reimbursed up to $50 per use.

Name

Home Address

City

State

Zip

Daytime Phone Number

Ext

Employer

Bikepool, Carpool, or Vanpool Contact Name

Date and Time of ERH Service

Reason for ERH

Sickness or accident involving immediate family member (child, spouse, parent)

Unscheduled overtime or late meeting (i.e., no advance warning)

Breakdown or accident of carpool vehicle on way to or from work (i.e., not a vehicle that was planned to be in the shop for several days)

Carpool partner or vanpool driver had to unexpectedly leave work early (e.g., sickness, personal emergency)

Catastrophic emergency at home

Other unplanned personal emergency

Type of Transportation Used for ERH

Carshare Agency (Enterprise Carshare, Zipcar, etc.)

On-Demand Service (Lyft, Uber, etc.)

Taxi Company

Rental Car Agency

Other, please specify

Taxi Company Name

Taxi Fare

Rental Car Agency Name

Rental Fee

Other Transportation Fee

If Co-Worker Provided a Ride

Mileage One-Way (reimbursed at current government rate)

Destination Address

Co-Worker Name

Co-Worker Phone

Attach ERH Receipt

One file only.
Allowed types: gif jpg jpeg png bmp txt rtf html odf pdf doc docx ppt pptx xls xlsx.
The accumulated size of all files in this form cannot exceed 50 MB.

Signature

I certify that the above described Emergency Ride Home service was required for an unplanned personal emergency and meets all of the requirements of the DVRPC Emergency Ride Home Program.