Car Repair, Insurance, Vehicle Registration Requests:

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1 Transportation Assistance Program Please keep this page for your records. Car Repair, Insurance, Vehicle Registration Requests: Anoka County Minnesota Residents Only VERIFICATION CHECKLIST: Please submit the following documents to the 2nd floor reception desk at the Blaine Human Services Center, or via fax, or mail (see fax/address at bottom of the page): Fill out and sign all pages of application Copy of driver s license (showing current address) and/or the yellow DMV receipt Copy of Title of Vehicle or proof of ownership vehicle must be registered in your name Copy of insurance card (not bill). If need help with insurance, see note below Copy of Pay Stubs for the last 30 days (if employed) or proof of other income *NOTE: ASSISTANCE FOR INSURANCE, TABS OR VEHICLE REGISTRATION AVAILABLE FOR CURRENT MFIP/DWP CLIENTS ONLY Provide copy of your insurance bill (if applying for help with your current insurance) or three quotes from local insurance agencies (if applying for help to start a new policy). Copy of tabs bill (or print out from DMV) if applying for assistance with tabs/title transfer. Information can be faxed directly to Irina at Once you submit your application, you will have 30 days to supply all required documents. If after 30 days, you have not supplied the required documents your request for service will be denied based on insufficient information. Once your repair is approved you will have 14 days to have your vehicle repaired. After 14 days, if you have not had repairs completed your application will be considered inactive and you may need to reapply. CEAP (Transportation Coordinator), th Ave., Suite 230, Blaine MN Phone Fax Cars for Neighbors a DBA of Free to Be, Inc th Ave., Suite 230, Blaine MN Phone Fax

2 Transportation Assistance Program Please keep this page for your records. Car Donation Requests: Anoka County Minnesota Residents Only GUIDELINES: 1. Must be a continuous resident of Anoka County for at least the past six months 2. Age 21 or older 3. Must be employed 4. Must have income in the very low to moderate income range listed on the application 5. Must demonstrate a minimum of $ monthly disposable income 6. Must have a valid driver s license that shows current address 7. Must be able to get car insurance and provide proof prior to receiving car 8. No previous assistance from Cars for Neighbors or Free to Be, Inc. 9. No other working vehicles in applicant s household VERIFICATION CHECKLIST: Please submit the following documents to the 2nd floor reception desk at the Blaine Human Services Center, or via fax, or mail (see fax/address at bottom of the page): Fill out and sign all pages of application Provide documentation of all income * Provide copy of rental agreement or lease * Provide all student/personal loan and credit card statements * Provide monthly childcare expense documentation * Copy of driver s license for every registered driver in your household (showing current address or the yellow DMV receipt). If drivers license was issued within the past six months please provide proof of continuous residency in Anoka County as well (lease, utility bill, etc.) Take Dollars into $ense Class. The class is an hour and a half long. The class is offered once a month. Call to register for the next class or attend a car maintenance and budgeting class taught by one of our volunteers. * This will be used to establish monthly disposable income Once you submit your application, you will have 30 days to supply all required documents. If after 30 days, you have not supplied the required documents your request for service will be denied based on insufficient information. Please note: After all the information is received, verified, and accepted you will be put on our waiting list. Once a car is available you will be notified. If you have been on the waiting list more than 60 days we will complete a follow-up verification of your information. Cars for Neighbors a DBA of Free to Be, Inc th Ave., Suite 230, Blaine MN Phone Fax

3 Transportation Assistance Program Application Name: (Print) Address: City,ST,Zip Phone # Maxis Case: Other Phone # List the people who live in your home: Name Date of Birth Relationship SSN Driver s License # 1. SELF ) Is anyone in the home currently receiving assistance? Yes No If Yes, Type: MFIP/DWP FS MA 2) How long have you lived in Anoka County? 3) Marital status: Single Married Widowed Divorced Separated 4) Are you a U.S. citizen? Yes No If No, Alien Number: Date Card Expires: 5) Assistance needed? Car Repair Insurance (MFIP/DWP clients only) Vehicle Registration/Tabs (MFIP/DWP clients only) Donated Vehicle (Are you able to drive a stick vs automatic)? Yes No 6) Are you working? Yes No If yes, name of employer: Hours per week: Hourly wage: Start date: Is your spouse/significant other working? Yes No If yes, name of employer: Hours per week: Hourly wage: Start date: 7) Are you looking for work? Yes No Is your spouse/significant other looking for work? Yes No 8) Cars in the household: Year Make Model Mileage Amount Owed 9) Is the car drivable? Yes No For Car Repair, describe vehicle problem: My signature acknowledges that the information provided is correct, true and complete. Applicant's Signature: Date: Agency Signature: Page 1 of 4

4 CEAP (Transportation Coordinator), th Ave., Suite 230, Blaine MN Phone Fax Cars for Neighbors a DBA of Free to Be, Inc th Ave., Suite 230, Blaine MN Phone Fax AUTHORIZATION FOR RELEASE AND EXCHANGE OF INFORMATION and Permission to Verify Application I, permit CEAP (Community Emergency Assistance Program) and Cars for Neighbors to share and verify the information to determine benefits I may be eligible for. They can share information with: Anoka County Community Action Program Anoka County Income Maintenance Department Anoka County Job Training Center My employer Car insurance company Auto Dealer Garage Other: (Must specify) Data given by the county may include: What help CEAP may give me. Information about help the CEAP gives me now. The amount the CEAP may pay them. COUNTY OF ANOKA Anoka County Job Training Center CEAP Cars for Neighbors This data is private. The CEAP and Cars for Neighbors can only give this information if they have my permission in writing. They may give data without my permission if otherwise provided by state or federal law. I understand I may refuse to release this data. If I refuse, the CEAP and Cars for Neighbors may be unable to help me resolve my crisis. The CEAP and Cars for Neighbors verifies the information provided on the application is correct, true and complete. Cars for Neighbors verifies information through exchange of information with Anoka County agencies. For the Cars for Neighbors Program, Cars for Neighbors will verify that there are no working vehicles in the household. This verification will be done using DMV vehicle ownership information. Clients will be ineligible for assistance if they are currently in collections for an existing loan with CEAP, have defaulted on a previous loan or are currently behind on a loan with CEAP before it goes into collections. Clients will also be ineligible if they are not in compliance with other agencies collaborating with Cars for Neighbors. I hereby authorize Cars for Neighbors and the CEAP to release and exchange information pertaining to my applications and eligibility for programs/services they administer for the purpose of evaluating my need for assistance. I authorize release and exchange of the information requested for a car donation or car repair. This permission is good for one year from the date I sign it. Signature of person authorizing release Date Warning: Section 1001 of Title 18 of US. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. as to matters within its jurisdiction. Page 2 of 4

5 Participation Survey- Please circle the appropriate selection: Sex: Female Male Age: 18 and under (youth) or older (senior) Hispanic: Yes No Single Race or Multi-Race or Other White American Indian and White Black / African American Asian and White Asian African American and White American Indian or Alaska Native American Indian and African American Native Hawaiian or Pacific Islander Are you Homeless? Yes No Are you a Veteran? 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 Severely Disabled? Yes No If yes, describe: Definition: If you 1) use a wheel chair or another special aid for 6 months or longer; or, 2) are unable to perform one or more functional activities (seeing, hearing, having one s speech understood, lifting and carrying, walking up a flight of stairs, and walking), or need assistance with activities of daily living (getting around inside the home, getting in or out of bed or a chair, bathing, dressing, eating or toileting) or instrumental activities of daily living (going outside the home, keeping track of money or bills, preparing meals, doing light housework and using the telephone); or 3) are prevented from working at a job or doing housework; or, 4) have a selected condition including autism, cerebral palsy, Alzheimer s disease, senility, dementia or mental retardation; or, 5) are under 65 years of age and are covered by Medicare or receive Supplemental Security Income (SSI). Income Information: Circle family size (total number in household including foster children) then, without changing rows, Circle the amount listed to the right of the family size column that includes your total household income. Income Categories Family Size Very Low Low Moderate Over Income 1 $18,200 or below $18,201 thru $30,350 $30,351 thru $46,100 $46,101 or above 2 $20,800 or below $20,801 thru $34,650 $34,651 thru $52,650 $52,651 or above 3 $23,400 or below $23,401 thru $39,000 $39,001 thru $59,250 $59,251 or abovd 4 $26,000 or below $26,001 thru $43,300 $43,301 thru $65,800 $65,801 or above 5 $28,410 or below $28,411 thru $46,800 $46,801 thru $71,100 $71,101 or above 6 $32,570 or below $32,571 thru $50,250 $50,251 thru $76,350 $76,351 or above 7 $36,730 or below $36,731 thru 53,700 $53,701 thru $81,600 $81,601 or above 8 $40,890 or below $40,891 thru $57,200 $57,201 thru $86,900 $86,901 or above More than 8 Talk to agency staff for help in determining income category for your household. I certify that the information on this form is accurate and complete. I authorize Cars for Neighbors to verify the information provided if necessary. Signature Date Page 3 of 4

6 How will this service help you? Please explain how our Transportation Assistance Program 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. My signature acknowledges that I understand this statement will not be used for qualification and that I may be contacted at a future date regarding this statement. Signature Date Page 4 of 4

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