Thank you for considering the Revolving Car Loan Program for your client. Before passing this application along, here are a few items of note.

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1 Hello Human Service Agency Representive! Thank you for considering the Revolving Car Loan Program for your client. Before passing this application along, here are a few items of note. In this application packet you will find: o Selection Criteria for Revolving Car Loan Program o Revolving Car Loan Checklist o Revolving Car Loan Application o Revolving Car Loan Budget This program is for an individual (or family) who is currently unemployed or underemployed and could greatly increase their earnings if they had access to transportation. Further requirements are outlined in the packet, see Selection Criteria for CSG Car Loan Program. Ideally, employment or an opportunity for greater employment will have been identified for the individual. The agency role in this process is significant. We are asking the agency representative who nominates a client to act as an advocate on behalf of the client. This needs to be an individual who is ready to make positive change in their life and with transportation will have the ability to pay back the auto loan and car insurance along with other car maintenance expenses. Acting as an advocate for this individual might include: o Attending meetings as part of the review process o Working through a realistic budget with the individual o Helping the individual get all review materials as identified in the application attached to the review committee o Following up with the individual after the car has been secured. If you believe your client is a good fit for this program please fill out the application included in this packet and /mail it either: Beth Burke Support Service Coordinator Community Strategies Group ext 113 bburke@csgpa.org 700 Sawmill Road Suite 101, Bloomsburg Pa Adrienne Mael President/CEO United Way of Columbia and Montour County ceo@cmcuw.org 238 Market St., Bloomsburg Pa 17815

2 Selection Criteria for Revolving Car Loan Procedure Program Purpose The purpose of the Community Strategies Group Car Loan Program is to: Assist applicants and families who lack transportation Enable applicants and families to work and increase their income through the purchase of a vehicle. Eligibility Requirements All applicants must meet the following eligibility requirements: 1. Family household income must be at or below 60% Area Median Income (AMI) 2. Must be using vehicle to increase income by: gaining employment, changing employer, or increasing hours at employment 3. Must have sufficient earnings to repay the loan. 4. Must have an established relationship and be recommended by a member of a human services agency who can verify that the applicant has demonstrated a commitment to work towards self-sufficiency. 5. Must agree to participate in Budgeting Counseling and ongoing budget reviews. 6. Must agree to participate in vehicle prevention maintenance training and have vehicle serviced as prescribed. 7. Must agree to notify Community Strategies Group and be willing to participate in employment readiness programs if employment is lost or reduced. 8. Must agree to maintain appropriate vehicle insurance. 9. Must agree to keep vehicle registration and inspection current. Funded Program

3 Revolving Car Loan Checklist Step 1: Potential applicant or recommending agency reaches out for application. Step 2: Potential applicant/recommending agency submits application. Step 3: If applicant meets criteria, an initial meeting is called with the human service agency representative, potential car loan applicants, and 1-2 members of the Revolving Car Loan committee for an initial discussion. Before the meeting the potential applicant is given a checklist of items to bring to the meeting including: Revolving Car Loan Budget If working, paystubs At the initial meeting other materials may be requested. Step 4: After the initial meeting applicant has two weeks to provide additional information to Revolving Car Loan committee. Once all information (application, paystubs, budget) is submitted, and if the potential applicant is stilled deemed to meet the program guidelines, the Revolving Car Loan committee is called. Agency representative and potential applicants attends the meeting. Step 5: If applicant is awarded the car they will need to secure: Valid PA driver s license Car insurance Step 6: The client (or applicant) and committee member will work together to identify possible cars which the client (or applicant) will test drive. Step 7: Appointment is made at First Columbia Bank and Trust Co. to secure loan and sign official agreement with the Revolving Car Loan program. Applicant picks up car.

4 Date Received: REVOLVING CAR LOAN APPLICATION HOUSEHOLD COMPOSITION: List the head of your household (HOH) and all members who live in your home. Give the relationship of each family member to the head. Member Social Security No. Full Name Relationship Birth Date No. 1 HOH CONTACT INFORMATION: Home Phone: Cell Phone: Other Phone: Current Address: County: Are you a US Citizen? Yes No Do you have a Current/Valid Driver s License? Yes No If yes, License #/State of issue: Are there other family member s that have a valid/current Driver s License and may drive the vehicle? Yes No Name: License #/State of Issue Name: License #/State of Issue INCOME: Please mark types of income received and list each household member s current source of income and monthly amount. To be eligible for this program you must be at or below 60% of the Area Median Income (AMI). Please fill out the following section for the sole purpose of eligibility determination. Household Income Information What type of income or assistance do you and your family receive? Employment income: If yes: Employer Name: Employer Address: Employer Phone #: Fax #: Unearned income: (Monthly) Source of unearned income : Food Stamps: MA SSI SSP Unemployment Compensation: Other: If yes, what? Child Support: What County:

5 FAMILY MEMBER NAME SOURCE OF INCOME MONTHLY INCOME ASSET INFORMATION: Please provide the following information regarding the household s assets. MEMBER NAME TYPE OF ACCOUNT BANK NAME CURRENT BALANCE To help us in the assessment and referral of your application please list any past Loans or Credit Cards that you have had: Lender: Loan Amount: Monthly Payment: paid in full: Balanced Owed: Making Payments In Collection Lender: Loan Amount: Monthly Payment: paid in full: Balanced Owed: Making Payments In Collection Lender: Loan Amount: Monthly Payment: paid in full: Balanced Owed: Making Payments In Collection I/We understand the above information is being collected to determine my/our eligibility. I/We authorize the owner/manager to verify all information provided on this application including income and other sources of credit and verification information, which, may be released to appropriate federal, state, or local agencies. I/We certify that the statements made in this application are true and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under federal law. Head of Household Signature: Date: Community Strategies Group Car Loan Program follows the Equal Credit Opportunity Act (the Act) is to promote the availability of credit to all creditworthy applicants without regard to race, color, religion, national origin, receipt of public assistance, sex, marital status, age, or the exercise of rights under the Consumer Credit Protection Act. ~Program funded by the United Way of Columbia and Montour Counties~ OFFICE USE ONLY: Referring Agency: Contact Person: Contact Phone Number:

6 NAME: DATE COMPLETED: REVOLVING CAR LOAN BUDGET MONTHLY LIVING EXPENSES EXPENSE AMOUNT COMMENTS EXPENSE AMOUNT COMMENTS MORTGAE/RENT MEDICAL/RX FOOD MEDICAL/RX TOILETRIES MEDICAL/RX ELECTRIC LOAN GAS LOAN FUEL - OIL CREDIT CARD TRASH CREDIT CARD WATER/SEWER CREDIT CARD PHONE LAYAWAYS CELL RENT TO OWN INTERNET MEALS OUT CABLE/SATELLITE LAUNDRY BUS/TRANSPORTATION CIGARETTES CAR PAYMENT PETS CAR INSURANCE FINES/LEGAL FEES GAS FOR CAR CHILD CARE LIFE INSURANCE CHILD SUPPORT RENTERS INSURANCE DIAPERS, WIPES ETC. HOME OWNERS INS. STORAGE OTHER INSURANCE ENTERTAINMENT CHURCH ALCOHOL CLOTHING SELF CARE TAXES PRESENTS MONTHLY EXPENSES TOTAL MONTHLY INCOME: Employment Child Support SSI Cash Assistance Food Assistance Other NET MONTHLY INCOME BALANCE (Minus/Plus) DO NOT PRINT BELOW THE ABOVE LINE *Verification of income as listed above will be required.

7 REVOLVING CAR LOAN AUTHORIZATION TO RELEASE INFORMATION Name: Date: Date of Birth: I hereby authorize Community Strategies Group and its staff to contact for information or materials which are deemed necessary to complete my application for participation or continued participation in the Car Loan Program; Specific information to release: Income Assets Employment Child care expenses Credit history Criminal history records References Other, please specify Other, please specify Other, please specify I understand that this authorization shall remain effective from the date of my signature to (date not to exceed one year). I may revoke this authorization by written, dated communication to any employee of Community Strategies Group. I also understand a fax or photocopy of this release will be considered as valid as the original. Client Name Date Phone Number Street Address City State Zip Code Agency Representative Name/Title Date Revolving Car Loan Program Committee Member present (if necessary) Date