CAR DONATION REQUEST. Please KEEP THIS PAGE for your records. CAR DONATION GUIDELINES:

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1 CAR DONATION GUIDELINES: CAR DONATION REQUEST Please KEEP THIS PAGE for your records. MUST BE A CONTINUOUS RESIDENT OF ANOKA COUNTY MN FOR AT LEAST THE PAST SIX MONTHS Age 21 or older Must be employed Must have income in the very low to moderate income range listed on the application Must demonstrate a minimum of $ monthly disposable income Must have a valid driver s license that shows current address Must be able to get car insurance and provide proof prior to receiving car No previous assistance from Cars for Neighbors or Free to Be, Inc. No other working vehicles in applicant s household Be able to pay a $100 pay-it-forward fee * * If you qualify for car donation a pay-it-forward fee of $100 will be due prior to receiving a vehicle. The proceeds are used to get a car prepared for the next vehicle recipient. CAR DONATION VERIFICATION CHECKLIST: Please submit the following documents to the 2nd floor reception desk at the Blaine Human Services Center, 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 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 and is offered once a month at the Blaine Human Services Center. Call to register for the next class. OR, you can take the TCF Financial Fitness Program online at you will be required to provide a printed copy of the certificate of completion. * 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 30 days we will complete a followup verification of your information. Cars for Neighbors th Ave NE, Suite 230 Blaine, MN Phone: Fax: info@carsforneighbors.org

2 CONTACT INFORMATION: Name (print): Maxis Case: Address: City, ST, Zip: Home Phone: Cell Phone: Work Phone: Other contact info: HOUSEHOLD INFORMATION: List all of the people who live at your residence below. NAME DATE OF BIRTH RELATIONSHIP SSN DRIVERS LICENSE# SELF Type of housing: OWN RENT SHELTER HOMELESS OTHER How long have you lived in Anoka County? DEMOGRAPHICS: Marital status: SINGLE MARRIED WIDOWED DIVORCED SEPARATED Are you a U.S. citizen? YES NO If no, Alien#: Date card expires: 1 st Language: 2 nd Language: Health Insurance: PRIVATE MEDICAL ASSISTANCE Are you working? YES NO If yes, please provide the following information: NAME OF EMPLOYER HOURS PER WEEK HOURLY WAGE START DATE Is your spouse/significant other working? YES NO If yes, please provide the following information: NAME OF EMPLOYER HOURS PER WEEK HOURLY WAGE START DATE Page 1 of 4 Effective 1/1/2017

3 Are you looking for work? YES NO Is your spouse/significant other looking for work? YES NO List other sources of income for entire household including any financial assistance below. NAME SOURCE OF INCOME AMOUNT RECEIVED HOW OFTEN ASSISTANCE REQUESTED: CAR REPAIR CAR DONATION Is the car driveable? YES NO Are you able to drive a stick shift? YES NO For car repair, describe vehicle problem: Vehicle needing service: YEAR MAKE MODEL MILEAGE AMOUNT OWED HOW WILL THIS SERVICE HELP YOU? (OPTIONAL) 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. SIGNATURE: Applicant signature: My signature acknowledges that the information provided is correct, true and complete. Page 2 of 4 Effective 1/1/2017

4 Participation Survey- Effective 3/28/2016 Applicant signature: Page 3 of 4 Effective 1/1/2017

5 Cars for Neighbors th Ave NE, Suite 230 Blaine, MN Phone: Fax: PERMISSION TO VERIFY APPLICATION AND AUTHORIZATION FOR RELEASE AND EXCHANGE OF INFORMATION I, permit Cars for Neighbors to share and verify the information provided to determine benefits I may be eligible for. The following agencies may receive and exchange information to qualify me for the Transportation Assistance Program: Anoka County Community Action Program (ACCAP) Anoka County Community & Governmental Relations Department Anoka County Income Maintenance Department Anoka County Job Training Center Community Emergency Assistance Programs (CEAP) My Employer Car insurance company Car repair shop Auto dealer BridgeLink Other This data is private. 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 that I have the right to refuse release of this data. If I refuse, Cars for Neighbors may be unable to assist me. Cars for Neighbors verifies that the information provided on the application is correct, true and complete with information through exchange of information with Anoka County agencies. Cars for Neighbors is not responsible for disclosure of the information or resulting damages in the event of a cyber-attack or data security breach. For car donation assistance, Cars for Neighbors will verify that there are no working vehicles in the household; verification will be done using DMV vehicle ownership information. I hereby authorize Cars for Neighbors to release and exchange information pertaining to my application 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 car repair or car donation. This permission is good for one year from the date I sign it. Applicant signature authorizing release: 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 4 of 4 Effective 1/1/2017