Car Repair Assistance Application

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Car Repair Assistance Application

"*" indicates required fields

Contact Information

Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email Address*

Home Phone*

Cell Phone*

Work Phone

Other contact info

How did you hear about us?

Household Information

List all of the people who live at your residence below

Name

Date of Birth

Relationship

Drivers License #

Name

Date of Birth

Relationship

Drivers License #

Name

Date of Birth

Relationship

Drivers License #

Name

Date of Birth

Relationship

Drivers License #

Name

Date of Birth

Relationship

Drivers License #

Marital Status*

Single

Married

Widowed

Divorced

Separated

Employment Information

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

Name

Source of Income

Amount Received

How Often

Name

Source of Income

Amount Received

How Often

Name

Source of Income

Amount Received

How Often

Name

Source of Income

Amount Received

How Often

Participation Survey

Please choose the appropriate selection

Sex*

Male

Female

Age Range*

18 and Under (Youth)

19 - 30

31 - 61

62 or Older (Senior)

Race*

White

Hispanic

Black/African American

Other

Are you Homeless?

Yes

No

Are you a Veteran?

Yes

No

Have you ever been incarcerated?

Yes

No

Are you getting out of a domestic violence situation?

Yes

No

Female Head of Household?

Yes

No

(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?

Yes

No

If so, describe

Income Information

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

Household Size

1 Person

2 Persons

3 Persons

4 Persons

5 Persons

6 Persons

7 Persons

8 Persons

Household Income

$25,760

$34,840

$43,920

$53,000

$62,080

$71,160

$80,240

$89,320

Vehicle Information

Is the car drive-able?

Yes

No

Describe any vehicle problems

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Mileage

Amount Owed on Vehicle

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.)

Agreement

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

Applicant Signature

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

Date

Contact

1111 31st Street
Lubbock, TX 79411

info@wrenchitforwardlbk.org

806-701-4568