Individuals wanting to purchase a car through this program must meet the following qualifications:

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1 Tier II Program Individuals wanting to purchase a car through this program must meet the following qualifications: You must have a verifiable job offer or be working at least 30 hours a week. If enrolled full time in a post-secondary education program (i.e. 9 or more credit hours) you must work a minimum of 25 hours per week. Must provide proof of full time enrollment. You must have a driver s license in the state in which you reside You must be insurable (no DWIs or DUIs) You must not have any other vehicle in your household You must be drug free and have no extensive criminal background You must be able to pay for your insurance, and the ongoing expense of fuel and car maintenance. You must be able to cover fees for taxes, tags and title (approximately an additional $500). If you are under the age of 25, you must have children You must meet the income requirements listed below Must attend the VFC Car Orientation Program, prior to receiving your vehicle The cars provided in this program are generally divided into two categories: 1. Older models start at $1,100. Price includes a 30 day/1,000 mile power train warranty. AAA is optional with the additional cost due at purchase. 2. Cars produced from 1997 to Prices begin at $2,000, and include a 6-month/6,000 mile limited warranty. A loan is not offered for this program so if you are not able to pay the full price in one lump sum, you must be able to obtain your own loan before you submit an application. Anyone wishing to apply for a car through the Tier II program must complete this application. Please make sure all required documents are submitted at the time the application is sent or the application will not be processed. See page 9 for required documents. Check the website at or tmcfadden@vehiclesforchange.org for more information. Income Guidelines Number of Persons in Household Maximum Income Level 1 $25,000 2 $37,400 3 $47,000 4 $56,500 5 $66,000 6 $75,600 Please send completed packet to: Vehicles For Change 4111 Washington Blvd. Halethorpe, MD Attn: Awards Coordinator 1

2 APPLICANT DATA Name of Applicant: Address: Street City State Zip Home Phone: Work Phone: Cell Phone: Address: S.S. # Driver s License: Do you posses a valid driver s license? Yes No Can you drive a motor vehicle? Yes No Can you drive a stick shift/manuel transmission? Yes No Are there others in your household licensed to drive? Yes No If yes, Name and relationship: HOUSEHOLD MEMBERS (including applicant) Name Relationship to applicant Social Security Number Date of Birth SELF If additional space is needed for family members, please use the back of this page. NOTE: Per Maryland Law Every child under 6 years old, regardless of weight, and every child weighing 40 pounds or less, regardless of age, must be secured in a U.S. DOT approved child safety seat. Children and young people up to 16 years of age must be secured in seat belts or child safety seats, regardless of their seating positions. It is strongly recommended that all children ride secured in the rear seat. Drivers and front seat passengers, regardless of their ages, are required to wear seat belts. It is strongly recommended that all occupants wear seat belts. Number of children that are not living in your home: Ages: Are any of your children in day care? Yes No How many? Hours: Are there any other vehicles in the household? Yes No If yes, name of person: Do you have access to this vehicle? Yes No If relevant to your application, list any family members who are disabled. Give disability. (You will be required to submit medical documentation of this disability if selected.) How much money will you have to spend on a vehicle if your application is approved? $ 2

3 HOUSEHOLD INCOME AND EXPENSES Your income and expense information must be completed accurately. Applicants should complete this part of the application with someone from the sponsoring agency (if applicable). Items below are on a monthly basis. Take Home Wages/Salary (after taxes) $ (If you are paid weekly take the earnings amount a multiple it by 52 and then divide by 12; if you are paid by-weekly, multiply your check by 26 and divide by 12) Child Support (Only include if you are sure to receive it every month) Food Stamps TANF or other State support (Only include if you will receive for at least 9 more months) SSI (amount of monthly check) Other Income (list on lines below) TOTAL OF ALL INCOME LISTED ABOVE _ 3

4 Budget Sheet Housing Costs Mortgage/Rent House Repairs Insurance Total Utilities (Monthly Bills) Gas and Electric Water (if your water bill comes every 3 months divide by 3) Phone (include cell) Total $ Child Care and School Expenses Monthly Childcare Fees School Materials Other Total $ Medical Expenses (you will need to determine or estimate Medical on a monthly basis) Doctor Visits Dentists Prescriptions Eye Total $ Transportation Car ownership Car Insurance Gas Car Repairs Monthly Cab or Bus Fare Ride Payments to Friends Total $ Gifts (you will have to divide the amount by 12 to get your monthly costs) Christmas Birthday Other Total Food - Meals and Groceries Including Food and Non-Food Items (if you receive food stamps, this must be equivalent to the amount received and listed above) Lunches $ Spending on Dinners Out $ Groceries $ Groceries including: Cleaning supplies, household items, cosmetics, cigarettes Total Clothing (include shoes, coats etc. : estimate monthly cost for yourself and family) Total Entertainment/Recreation Cable or Dish $ DVD rentals $ Vacations (divide total by 12) $ Other $ Total Total Expenses (add all the above items in the last column) Total Available Monthly Funds (income minus expenses) Total Have you received Cash Assistance or other benefits in the past 24 months? (Food stamps, medical assistance, POC etc.) Yes No For how many months? From which agency? Money in Savings or Other account 4

5 Demographical Information Please provide the following information which will be used by authorized personnel for statistical purposes only. This data will not impact the selection process. Vehicles For Change, Inc. does not discriminate based on race, sex, religion or national origin. Race (please check one only): White, non-hispanic Black, non-hispanic Asian/Pacific Islander American Indian/Alaskan Native Hispanic Other Household Status: Single, male head of household Single, female head of household Two adult household Income Guidelines NOTE: The income is annual and before taxes (Gross Amount). If more than one adult live in the household you must include their income as well. YOUR HOUSEHOLD ANNUAL INCOME _ Other Income - Child Care, Food Stamps etc. _ Income of Other Individuals in the House _ Total Household Income: Total Number of Persons in Household: Your maximum income level (see chart on page 1) _ 5

6 Are you currently employed? Yes No Vehicles For Change, Inc. EMPLOYMENT Number of hours per week? Hours: Begin am/pm End: am/pm Shift 1 st 2 nd 3 rd Current Employer: Address: Contact Person: Phone: How long have you been employed there? Position: List your last three employers, your position with that employer, and the dates of the employment: If you are not currently employed, do you have a verifiable job offer? Yes No If yes, please list the following: Employer: Address: Contact Person: Position: How are you getting to work now? How will a car allow you to become/remain self-sufficient and improve your life? You may use back of this page to write yourresponse. PLEASE NOTE: Distribution of cars to eligible applicants depends on the availability of cars. From the submission of your application to the receipt of your car, the process may take from one to six weeks. Please be patient. Applicants/Sponsoring agencies will be advised as to the status of the application as they move through the process. Completion of this application does not guarantee that you will receive a car. Please verify all information is complete prior to submitting. You will not be contacted for additional information. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSES or RETURNED. 6

7 Professional Reference To be completed by Sponsoring Agency, Employer, or Church Official. Sponsoring Agency/Employer/Church Official: Phone: Mailing Address: Contact: Fax: Why would the applicant be a good candidate for a car from Vehicles For Change, Inc.? Please explain Explain any extenuating circumstances: Signature of Reference: Date: 7

8 Photographic Consent Form Vehicles For Change may be interested in sharing your story with others via newsletters, , fliers, postcards, media, etc. Sharing this information will allow Vehicles For Change to continue its mission to assist families in achieving financial and personal independence. Stories and photos encourage people to donate their vehicles, which allows VFC to assist more families. If you agree to allow VFC to use your photo/story, please complete Section A. If you prefer that we refrain from publishing your photo/story, please complete Section B. Section A: The undersigned does hereby authorize VEHICLES FOR CHANGE and/or its associates, assistants, or subcontractors to photograph/film. Name (please print) The undersigned authorizes Vehicles for Change to permit the use and display of said photographs for use in any publication, multimedia production, display, advertisement or World-Wide Web Publication. The undersigned agrees that Vehicles for Change may use name, likeness, or biographical information supplied by the undersigned. The undersigned releases and forever discharges Vehicles for Change and its employees from any and all claims and demands arising out of or in connection with the use of said photographs / images, including but not limited to, any claims for invasion of privacy or defamation. Accepted and Agreed: Signature of Subject Signature of VFC Witness Date Date Section B: I do not wish to have my story or photograph utilized in any production to further the mission of Vehicles for Change. Signature of Subject Printed Name of Subject Date Signature of VFC Witness Printed Name of Witness Date 8

9 **Submit With Your Application** 1. Copy of Social Security card for all household members 2. Copy of driver licenses for all drivers in the household 3. Proof of income (most recent three paystubs) or letter from the employer on company letterhead stating income, hours worked, state date and telephone number to be contacted ( only if you have not been employed for more than 30 days)). 4. Three-year driving record (to be reviewed for insurability) for everyone who is licensed to drive in your household. 5. Registration record, if Maryland resident, to assure that no insurance violations or other flags exists. Maryland residents must use MVA form DR-057 (sample attached) to secure driving and registration records. Submit reports with application. Read Carefully and Sign Below I have read the requirements as outlined on page one of this application and I meet each of the requirements necessary to qualify for a car from Vehicles for Change, Inc. The information provided by me in this application is true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for is cause for the rejection of this application. Further I understand and agree that evaluation of this application does not guarantee a car from Vehicles for Change, Inc. I hereby provide permission to the Department of Social Services or sponsoring agency to release any information to Vehicles for Change pertaining to my address, phone, work and/or name. I also provide the Department of Social Services with permission to update Vehicles for Change on any changes or sponsoring agency to this information until my automobile loan is paid in full. Signature of Applicant(s) Date 9

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