Vehicle Application ALL SECTIONS (INCLUDING THE ATTACHED BUDGET FORM) MUST BE COMPLETED FOR YOUR APPLICATION TO BE REVIEWED CONTACT INFORMATION Name: Address: City: State: Zip: County/Township: Day Phone: ( ) - Evening Phone: ( ) - Cell Phone: ( ) - Email Address: Best time to contact: How were you referred to the Wheels to Work Program? Page 1
EMPLOYMENT Please check one of the following: [ ] Employed, full-time [ ] Unemployed, not looking [ ] Employed, part-time [ ] Student [ ] Unemployed, looking for work Credits per semester: Current Employer: Supervisor: Supervisor s Phone: ( ) - Number of hours worked in a week (on average): HOUSEHOLD INFO AND CURRENT TRANSPORTATION List everyone living in your household (use additional paper if needed) Name Age Relation Self Do you need car seats or booster seats? [ ] YES [ ] NO Do you have a current, valid driver s license? [ ] YES [ ] NO Do you currently have car insurance? [ ] YES [ ] NO Do you currently have a reliable vehicle? [ ] YES [ ] NO How do you currently get to work / school? How many miles is it from home to work / school? Page 2
VEHICLE REQUEST Indicate which type(s) of vehicles you would like to be matched with: [ ] Car [ ] Van [ ] Truck [ ] SUV Can you drive a vehicle with a manual transmission? [ ] YES [ ] NO How much money do you have available to buy a vehicle from Wheels to Work? (Please include money from all sources, including DPW) Will you be using a public assistance Welfare (DPW/CAO) vehicle grant? [ ] YES [ ] NO Please indicate why you are applying for a vehicle from Wheels to Work. Include health, financial, debt, and family issues (use additional paper as needed). Page 3
Important things to know about Wheels to Work A Wheels to Work vehicle retails for between $1,800 to $3,000 on average. Pricing of each individual vehicle varies based on its age and condition. Wheels to Work WILL NOT finance 100% of the vehicle s price. PLEASE NOTE: Distribution of vehicles to eligible program applicants depends on the availability of vehicles. The process from submission of your application to receipt of a car may take anywhere from one to several months. Please be patient. Applicants will be advised as to the status of their application as they move through the matching process. Completion of this application does NOT guarantee that you will be matched with a Wheels to Work vehicle. Wheels to Work IS NOT responsible for the repairs or maintenance needs of the vehicle. o Once someone purchases a vehicle from Wheels to Work, the vehicle is their responsibility. This includes routine maintenance, repairs, new tires, and yearly inspections. For application review, you MUST COMPLETE ALL SECTIONS (including the attached BUDGET FORM), ANSWER ALL QUESTIONS, and sign and return your completed application to: Wheels to Work C/O Lancaster County Council of Churches 344 N. Marshall St Lancaster PA 17602-2427 Tel: 717.291.2261 ext.226 Fax: 717.291.6403 ATTN: Wheels to Work INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED FOR PROGRAM ELIGIBILITY. Your Signature: Date: Page 4
HOUSEHOLD INCOME AND EXPENSES INFORMATION YOU MUST PROVIDE PROOF OF INCOME WITH YOUR COMPLETED APPLICATION (please include 2 or 3 of your most recent pay stubs, W2 form, disability income statement, previous year s tax return, and any other relevant documents) Please check the box closest to your entire household s gross (before taxes) yearly income ONLY include wages/salary: [ ] $25,592 or less [ ] $43,547-$52,523 [ ] $25,593-$34,569 [ ] $52,524-$61,500 [ ] $34,570-$43,546 [ ] $61,501 or more Your income and expense information must be completed accurately. Note that the items are all on a monthly basis. NET INCOME PER MONTH Take Home Wages / Salary (after taxes) If you receive a check each week, multiply the amount by 4; if you receive a check every 2 weeks, multiply the amount by 2. Child Support Only include child support if you are guaranteed to receive it every month. TANF or Other State Support SSI (amount of monthly check) Other Income (list on lines below) A. TOTAL OF ALL INCOME LISTED ABOVE Page 5
NET EXPENSES PER MONTH HOUSING COSTS Mortgage/Rent $ House Repairs $ Insurance (rental or home) $ B. TOTAL HOUSING EXPENSES UTILITIES (MONTHLY BILLS) Gas and/or Electricity Water Phone (land and/or cell) $ $ $ C. TOTAL UTILITIES CHILD CARE AND SCHOOL EXPENSES Daycare Fees School Materials Student Loan Payments Other D. TOTAL CHILD CARE AND SCHOOL EXPENSES MEDICAL EXPENSES You will need to determine or estimate medical expenses on a monthly basis. Doctor Visits Dentist Prescriptions (Medicine) Eye Outstanding Medical Bills E. TOTAL MEDICAL EXPENSES TRANSPORTATION Car ownership monthly costs only apply IF you currently own a car. Car Insurance Gas Car Repairs Monthly Bus or Cab Fares Ride Payments to Friends _ F. TOTAL TRANSPORTATION EXPENSES Page 6
FOOD MEALS AND GROCERIES Include food and non-food items such as cleaning supplies, household items, toiletries, cosmetics, and cigarettes. Do you receive Food Stamps? [ ] YES [ ] NO If YES, how much per month? Not including food stamps, how much do you spend per month on: Lunches Dinners Out Groceries Household Items/Toiletries G. TOTAL FOOD EXPENSES (not including food stamps) CLOTHING Include shoes, coats, etc estimate the cost per month. Self Other Household Members H. TOTAL CLOTHING EXPENSES ENTERTAINMENT / RECREATION / EXTRA EXPENSES Cable / Satellite Dish Internet Access DVD Rentals / Netflix Other I. TOTAL ENTERTAINMENT EXPENSES TOTAL EXPENSES (Add together the totals of lines B, C, D, E, F, G, H, I) AVAILABLE MONTHLY FUNDS (Line A [Total Income] minus Total Expenses) Have you received cash assistance or other benefits in the past 24 months? Benefits include food stamps (SNAP), medical assistance, cash assistance, etc. [ ] YES [ ] NO How many months? From what agency? Money in savings account / other savings INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED FOR PROGRAM ELIGIBILITY. Page 7