Application

Step 1 of 5

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This request if for(Required)

Vehicle Repair

Vehicle Donation

First Name(Required)

Last Name(Required)

Email(Required)

Primary Phone #(Required)

Alternative Phone #

Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

How long have you lived in this County?(Required)

Preferred Language(Required)

Preferred written communication?

US Mail

MN Driver's License #(Required)

Is the Driver's License valid?(Required)

Yes

Upload a copy of your Driver's License(Required)

Either scan or take a photo of your license and upload.

Max. file size: 5 MB.

Maximum file size - 5 mega bytes.

Upload a copy of your proof of insurance(Required)

Max. file size: 2 MB.

Maximum file size - 2 mega bytes.

Upload a copy of your vehicle title(Required)

Vehicle must be registered in your name

Max. file size: 2 MB.

Maximum file size - 2 mega bytes.

Enter the name of the agency or organization who sent a Referral on your behalf?

Have you used our program in the past?(Required)

If yes, when?(Required)

Type of Previous Program Use(Required)

Donated

Repaired

In City Limits?(Required)

Yes

Public Transportation Available?(Required)

Yes

Medical Transportation Available?(Required)

Yes

Marital Status(Required)

Are you homeless?(Required)

Yes

Are you a Female Head of Household?(Required)

Definition: a married or unmarried female who maintains a household for a dependent, or non-dependent relative, and provides more than half of the dependent's financial support.

Yes

Is anyone receiving financial assistance?(Required)

Yes

What type of financial assistance?(Required)

MFIP/DWP

SNAP

WIC

SSI

Other

If yes, is anyone currently in sanction?(Required)

Yes

Are you currently on probation?(Required)

Yes

Have you ever had your Driver's License suspended/revoked?(Required)

Yes

Are you currently a Prime West member?(Required)

Yes

Employment status(Required)

Employed

Looking for Work

How many hours per week?(Required)

List all of household members, starting with yourself

List of Household Members

Click the plus icon '+' to add additional rows.

Race: A=Asian B=Black/African American I=American Indian/Alaska Native P=Native Hawaiian/Pacific Islander W=White/Caucasian M=Multi Race O=Other

Full Name

Date of Birth

Sex

US Citizen (Y/N)

Race

Hispanic (Y/N)

Veteran (Y/N)

Disability (Y/N)

Mental Illness (Y/N)

Has Income (Y/N)

Vehicles in the Household(Required)

Click the plus icon '+' to add additional rows.

Year

Make

Model

Plate #

Color

Mileage

Amount Owed

For Vehicle Repair, describe the vehicle issues

Applicant Financial Information

Are you currently employed?(Required)

Yes

Employment Income(Required)

Click the plus icon '+' to add additional rows

Employer

Phone

Date Started

Hourly Wage

Hours/Week

Monthly Income

TOTAL MONTHLY EMPLOYMENT INCOME(Required)

Upload your proof of income(Required)

30 days of paystubs (if employed), first 2 pages of tax return (if self-employed), or proof of other income (SNAP, SSI, etc.)

Drop files here or

Max. file size: 2 MB.

Maximum file size - 2 mega bytes.

Do you currently have a bank account?(Required)

Yes

Upload your latest bank account statement(Required)

Max. file size: 2 MB.

Maximum file size - 2 mega bytes.

Other Income

Fill in any Other Income that applies Leave blank if it does not apply.

Unemployment

Who receives it

Amount per Month

MFIP/DWP

Who receives it

Amount per Month

Food Support/SNAP

Who receives it

Amount per Month

SSI / RSDI / SSDI

Who receives it

Amount per Month

Child Support

Who receives it

Amount per Month

Retirement or Veterans Benefits

Who receives it

Amount per Month

TOTAL MONTHLY OTHER INCOME

Expenses

Housing Expenses

Amount per Month

Electric

Amount per Month

Propane/Fuel

Amount per Month

Phone

Amount per Month

Cable

Amount per Month

Car Insurance

Amount per Month

Food

Amount per Month

Credit Cards

Amount per Month

Child Care

Amount per Month

Loans

Amount per Month

Other

Amount per Month

TOTAL MONTHLY EXPENSES(Required)

Total up all of your monthly expenses and enter that amount here.

Authorization for Release and Exchange of Information & to Verify Application

I permit Car Care Program to share and verify the information to determine benefits I may be eligible for.

They can share information with;

County Human Service agency
West Central Minnesota Community Action, Inc.
Workforce Center
Horizon Public Health
Love INC
PrimeWest Health
Salvation Army
My employer (shared below)
Auto dealer (shared below)
Car insurance company (shared below)
Garage (shared below)

Data given may include:

Verification of sanction status
The amount of eligibility I may be eligible for from their agency.

This data is private. The Car Care Program and the other named agencies can only give this information if they have my permission in writing. They may give data without my permission if otherwise provided by state and federal law. I understand I may refuse to release this data. If I refuse, the Car Care Program may be unable to help me resolve my crisis. The Car Care Program verifies the information provided on the application is correct, true and complete. The Car Care Program verifies information through exchange of information with Douglas County agencies. The Car Care Program will verify that there are no working vehicles in the household.This verification will be done using DMV vehicle ownership information.

Clients will be ineligible if they are not in compliance with other agencies collaborating with the Car Care Program.

By checking the box below and signing this form, I hereby authorize the Car Care Program to release and exchange information pertaining to my applications and eligibility for programs/services they administer for the purpose of evaluating my need for assistance. I authorize release and exchange of information requested for a car donation or car repair. This permission is good for one year from the date I sign it.

Authorization to release/exchange information

I hereby authorize the Car Care Program to release and exchange information pertaining to my applications and eligibility for programs/services they administer for the purpose of evaluating my need for assistance.

Name of my employer

Name of Auto dealer

Name of Car insurance company

Name of Garage/Mechanic

Vehicle Repair Liability Waiver

What you need to know about Car Care Program:

The Car Care Program is primarily made up of volunteers to help you with your transportation needs if they can be fixed within the time and budget allowable. If the cars are deem non repairable, the Car Care Shop Manager or Executive Director will communicate a go forward plan for your vehicle.

The Car Care Program cannot and will not assume any warranty work for the volunteers who will be fixing your vehicle.

Remember, the technicians are all volunteers. These people are volunteering as part of their faith-based need for us to help our brothers and sisters. Volunteers want to help and their only tip is a big thank you.

Repair Liability Waiver

I understand that the cars are repaired by volunteers, most of whom are not professional automotive technicians, although at least one professional will be available for the volunteers to get advice from.(Required)

Check to mark that you understand and agree

I understand that the volunteers agree not to undertake any repair for which they believe they do not have the proper skills or tools.(Required)

Check to mark that you understand and agree

I agree that if I experience any problems with the repair work that has been done, I will immediately stop driving the car and telephone the Car Care Program, at 320-460-7911. If I obtain an answering machine, I will leave a message. I also agree that I will promptly bring the vehicle in for examination if I am requested to do so.(Required)

Check to mark that you understand and agree

If the vehicle is deemed unrepairable, the client will have a 7-day grace period to turn in or junk car with Car Care or pay for a tow back to the property.(Required)

Check to mark that you understand and agree

Acknowledgement of Correct Information

My signature acknowledges that the information provided is correct true, and complete.

RELEASE AND WAIVER

I HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE ANY STAFF OR OWNERS....FOR ANY PERSONAL INJURY OR PROPERTY DAMAGE THAT IS CAUSED BY THE NEGLIGENCE BY ANY OTHER VOLUNTEER, ANY STAFF OR OWNERS BY SIGNING THIS AGREEMENT, I AGREE THAT IT IS MY INTENTION TO EXEMPT AND RELIEVE ANY STAFF OR OWNERS FROM LIABILITY FOR PERSONAL INJURY OR PROPERTY DAMAGE CAUSED BY THE NEGLIGENCE OF ANY STAFF OR OWNERS.

I AGREE TO INDEMNIFY AND HOLD DOUGLAS COUNTY CAR CARE AND ANY STAFF OR OWNERS HARMLESS FROM ANY AND ALL CLAIMS, ACTIONS, SUITS, COSTS, EXPENSES, DAMAGES, AND LIABILITIES BROUGHT AS A RESULT OF MY INVOLVEMENT IN THE VOLUNTEER ACTIVITIES.

Consent for Release of Personal Information for Public Information Purposes

Do you hereby authorize Douglas County Car Care Program, Inc. the use of your name, words, and/or photograph in media promotion(s) of the Douglas County Car Care Program, Inc. services and their functions, activities, and programs.(Required)

I have been informed of the meaning of this release and that my signature on it amounts to a waiver of any claim I might assert against any official, employee, agent, or unit of Douglas County Car Care Program, Inc. arising from this release. This release shall bind my heirs and assigns.

Applicant Financial Information

Other Income

Expenses

Authorization for Release and Exchange of Information & to Verify Application

Vehicle Repair Liability Waiver

What you need to know about Car Care Program:

Repair Liability Waiver

Acknowledgement of Correct Information

RELEASE AND WAIVER

Consent for Release of Personal Information for Public Information Purposes

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