Steuben County Council on Aging • 317 S. Wayne St., Suite 1 B • Angola, IN 46703
C.O.A. Office (260)-665-8191 STAR Transportation (260)-665-9856
Reasonable Modification
Request Form
Please complete this form to request a reasonable modification of STAR Transportation services.
Submit the completed form to: STAR Transportation Coordinator
EMAIL at: [email protected]
or
MAIL to: 317 S. Wayne Street, Ste. 1-B, Angola, IN 46703
Name: _______________________________________ Todays Date: _____________
Email: __________________________________ Phone Number: ________________
Street Address:_________________________________________________________
City: ___________________________________ Zip Code:_____________________
Description of Your Request:
____________________________________________________________________
________________________________________________________________________________________________________________________________________
____________________________________________________________________
Are you able to use STAR Transportation services without this modification?
Yes No
Please Explain:_________________________________________________________