Car Repair Assistance Application

*CONTACT INFORMATION

*HOUSEHOLD INFORMATION

List all of the people who live at your residence below:

NAME

DATE OF BIRTH

RELATIONSHIP

DRIVERS LICENSE #

*DEMOGRAPHICS

Please list employment information below:

NAME OF EMPLOYER

HOURS PER WEEK

HOURLY WAGE

START DATE

List other sources of income for your entire household including any financial assistance below:

NAME

SOURCE OF INCOME

AMOUNT RECEIVED

HOW OFTEN

PARTICIPATION SURVEY

Please choose the appropriate selection:

(Definition: A married or unmarried female who maintains a household for a dependent or non-dependent relative, and provides more than half of the dependent's financial support.)

Income Information:

(Choose family size: A total number in household including foster children and your total household income.)

*VEHICLE INFORMATION

HOW WILL THIS SERVICE HELP YOU?

Please explain how our vehicle repair services can help you in your current situation. This is so we have a better understanding of your needs and how the program can better your life. Your statement WILL NOT be used for qualification. We may contact you at a future date to follow up on this statement.

I certify that the information on this form is accurate and complete. I authorize Wrench It Forward Inc. to verify the information provided.

SIGNATURE:

My signature acknowledges that the information provided is correct, true and complete.