Bishop Sullivan Center Drive KC to Work

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1 PROGRAM REQUIREMENTS To purchase a car through this program, you must: 1. Have no other cars in your household. 2. Be insurable (no SR-22s) 3. Have a valid driver s license and be at least 18 years old. 4. Have the means to pay up to $1,000 up front for the vehicle and a maximum of $500 for insurance, tax, licensing fees, and other costs associated with ongoing vehicle maintenance 5. Be current on all bills including but not limited to utilities, rent, or mortgage. 6. Have a total household income at or below 200% of the poverty level as detailed in the program s income requirements listed below. 7. Work 30+ hours a week, have been employed there for over 90 days, and be in good standing with your employer a. OR be a student in a post-secondary education program while working 25+ hours a week. You must provide proof of enrollment 200% Federal Poverty Guidelines Number in Household Gross Monthly Income is Lower Than: 1 $1,980 2 $2,670 3 $3,360 4 $4,050 5 $4,740 6 $5,430 7 $6,122 8 $6,815 For additional questions, please contact Phil Smith at or at phil.smith@bishopsullivan.org. Completed application and all attachments can be brought to your scheduled appointment, faxed to , or mailed to Bishop Sullivan Center, 6435 Truman Rd., Kansas City, MO

2 APPLICANT INFORMATION Name: Address: Phone: Do you have a valid driver s license? Yes No Can you drive a motor vehicle? Yes No Number of people currently living in your home Adults Children under 18 EMPLOYMENT INFORMATION Current Employer: Address: Position: Hours worked per week: Manager: Manager Phone: Manager

3 HOUSEHOLD INCOME Applicants must complete a household budget demonstrating their potential to afford a vehicle and the regular costs that come with car ownership. Your income and expense information must be completely accurate. Items below are on a monthly basis and are calculated for the entire household. Net Wages/Salary(after taxes, garnishments, etc) Social Security Income Child Support (Only include if you are sure to receive it every month.) Food Stamps Medicaid Other Governmental support (Only include if you will receive for at least 9 more months.) Other Income (list below) Total Income: Money in savings account $

4 HOUSEHOLD EXPENSES Mortgage/Rent Utilities (include phone and internet/cable) Childcare Medical Expenses Food, toiletries, cleaning supplies, etc. Clothing and other household items Current transportation (if you will still have even with a car) Entertainment Payday loans and credit cards Other expenses (list below) Total Current Expenses Available Monthly Funds (Total Income Less Total Current Expenses Anticipated Transportation Expenses Insurance Gas Maintenance Total Anticipated Transportation

5 SPONSOR INFORMATION Sponsoring Agency/School: Name: Phone: Why would the applicant be a good candidate for a vehicle from Bishop Sullivan Center? Signature of Sponsor: Date:

6 PROGRAM AGREEMENT As a potential recipient of a vehicle from Bishop Sullivan Center, I understand that I must fulfill the following responsibilities and agree to all terms: 1. Maintain my car with regular maintenance including tune-ups, oil changes and other normal maintenance procedures. These procedures are designed to reduce the chance of major mechanical problems and prolong the life of the car. 2. I understand that Bishop Sullivan Center is lending me $500 toward the total purchase price of the car and therefore, there is a lien on the title. At the end of one year, if I can prove that the car was insured during the entire time and still running, the $500 loan will be forgiven and the lien removed. 3. Bishop Sullivan Center provides no warranty on the vehicle. We do not pay for repairs. 4. Bishop Sullivan Center will not pay for any damages caused by collision, vandalism, negligence or faulty operation or maintenance. Negligence includes driving the car beyond the recommended oil change requirements or after the temperature gauge and/or warning light has registered HOT. This will result in extreme damage to the engine, and it can only occur through driver negligence. 5. I understand that the goal of this program is to provide me with reliable transportation so that I may help myself become financially secure. The car I receive may be 7-15 years old and may have more than 125,000 miles on it. The car may have some minor problems. These will not affect the safety or drivability of the car. I understand the Program Agreement and agree to the terms outlined above. Signature of Applicant(s): Date:

7 SUBMIT WITH YOUR COMPLETED APPLICATION 1. Last 3 pay stubs for all working adults in the household. 2. Proof on any other sources of income. 3. Copy of driver s license for the potential driver and picture ID for any other adults. 4. Copy of social security card for all members of the household. 5. Latest utility bills, current mortgage statement or letter on letterhead from your landlord showing your rent is current. 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 vehicle from Bishop Sullivan Center. 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 is cause for the rejection of this application. Signature of Applicant(s): Date:

8 PHOTOGRAPHIC CONSENT FORM Bishop Sullivan Center may be interested in sharing your story with others via newsletters, , fliers, Facebook, Twitter, our website and other digital or printed media. Sharing this information will allow Bishop Sullivan Center to continue its mission to assist families in achieving financial and personal independence. Stories and photos encourage people to donate their vehicles which allows us to assist more families. If you agree to allow Bishop Sullivan Center 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 authorizes Bishops Sullivan Center to photograph and/or film: Name: and family. The undersigned authorizes Bishop Sullivan Center to the use and display of said photographs and film for use in any publication, multimedia production, display, advertisement or internet publication. The undersigned agrees that Bishop Sullivan Center may use his/her name, likeness or biographical information supplied by the undersigned. The undersigned releases and forever discharges Bishop Sullivan Center and its employees from any and all claims and demands arising out of or in connection with the use of said photographs of film, including but not limited to any claims for invasion of privacy or defamation. Signature of Applicant(s): Date: Section B: I do not wish to have my story or photographs utilized in any production to further the mission of Bishop Sullivan Center. Signature of Applicant(s): Date: