Guaranteed Ride Home Reimbursement Form

DATE / TIME OF EMERGENCY

REIMBURSABLE TRIP COST*

Max amount is $70

TRIP ORIGIN*

TRIP DESTINATION*

NAME*

STREET ADDRESS*

CITY*

STATE*

ZIPCODE*

EMAIL*

PHONE*

HOW DID YOU GET TO WORK ON THE DAY OF THE EMERGENCY?*
VanpoolCarpoolBicycleWalkTransit

WHICH GUARANTEED RIDE HOME SERVICE DID YOU USE?*
TaxiRental Car/CarShareUber/LyftTransitMileage

IF MILEAGE: TOTAL TRIP MILES

IF MILEAGE: PERSON WHO PROVIDED THE RIDE

IF MILEAGE: CONTACT NUMBER FOR VERIFICATION:

WHAT CAUSED THE EMERGENCY?*
Personal or Family EmergencySudden illness or carpool driver or myselfCarpool driver had an emergencyMechanical breakdown of carpool vehicleUnexpected emergency overtime

Receipt*

Commuters are required to track greener trips with Go! Vermont to use the Guaranteed Ride Home reimbursement program.

I recorded my commute trip through the Go! Vermont App or Website.

By signing, I attest this information is correct and confirm this trip qualified for the GRH program. Please return this completed trip summary AND a copy of your receipt. Commuter has up to 30 days from the qualified trip to submit for reimbursement. Please allow 6 weeks from when we receive the form for review & reimbursement. The maximum amount for a reimbursed trip is $70 and the GRH reimbursement can only be used 4 times in a calendar year. The GSA-approved mileage reimbursement rate is $0.625 per mile effective July 1, 2025.

Complete this form and attach receipt for Taxi/Uber/Lyft/Transit/Rental Car/CarShare Send both documents to govermont@vermont.gov

COMMUTER SIGNATURE (PRINTED NAME)*:

DATE