Emergency Ride Home Reimbursement Request Form

1) Fill out the form below to request your money back. 2) Upload a copy of your receipt(s) or mail them with your full name and address to: San Francisco Emergency Ride Home Program 1455 Market Street, Suite 13B San Francisco CA 94103 REMEMBER:

-You must fill out this form within 30 days from the date of the trip -You must be 18 years or older at the time of the taxi ride to get paid back -You can get paid back for rides on taxis and public transit -You can get paid back up to $150 (tips not included) for a given emergency -You can get paid back for up to 4 emergencies per year -You cannot get paid back for Uber or Lyft rides

Work Address
Your starting/pick-up destination must be at your place of work

Destination/Drop-Off Address

Type of ERH ride taken and cost to be paid back:
For any ERH Ride types you did not use, leave the question blank.

Please remember: You cannot be paid back for trips taken by Uber/Lyft.

You can also mail your receipt(s) with your full name and address to: San Francisco Emergency Ride Home Program 1455 Market Street, Suite 13B San Francisco CA 94103