Name: Address: Address: Best time to contact:

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?

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

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? ________________

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?

$_______________________

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).

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

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.

 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:__________________

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.

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 $_______________

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 $_______________

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.