Car Repair Assistance Application

"*" indicates required fields

Contact Information

Address*

Household Information

List all of the people who live at your residence below
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Marital Status*

Employment Information

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

Participation Survey

Please choose the appropriate selection
Sex*
Age Range*
Race*
Are you Homeless?
Are you a Veteran?
Have you ever been incarcerated?
Are you getting out of a domestic violence situation?
Female Head of Household?
(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.)
Are you disabled?

Income Information

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

Vehicle Information

Is the car drive-able?
(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.)
Agreement
My signature acknowledges that the information provided is correct, true and complete.
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