WnW Application

Work 'n Wheels Application

(This will take approximately 30 to 45 minutes to complete)
NOTICE TO APPLICANTS

This is a HIPAA compliant form that keeps sensitive data safe. Additionally, our forms are served across protected 256 bit SSL (Secure Socket Layer) connection that uses a SHA256 Certificate. This is the same level of protection used by online banking or e-commerce providers. Submissions are encrypted with high-grade RSA 2048 then transferred and stored in our servers securely. Submission of this application does not guarantee approval of loan.
Are you applying for a vehicle loan or repair:*

LoanRepair
Applicant Name*

First NameMiddle NameLast Name
Social Security Number:*
###-##-####
DOB:*
Month/Day/Year
Address*

Address

Street Address Line 2

CityState / Province

Zip
Email:*
example@example.com
Home/Cell Phone:*
Will yo have a co-signer?*

Yes (please also complete co-signer section)No
Co-Signer Applicant Info

First NameMiddle NameLast Name
Co-Signer Social Security Number:
###-##-####
Co-Signer DOB:
Month/Day/Year
APPLICANT DEMOGRAPHICS
Gender:*

FemaleMalePrefer Not to DiscloseOther
Education Status:*

GED/HSEDHS DiplomaAABA or BSMA or MSPh.D.N/A (if n/a, please complete following)
Education Status Part II
Are you currently in school?    Yes   No
Is this alternative school?    Yes   No
Attained Certificate of Attendance/Completion?    Yes   No
Attained Other Post-Secondary Degree/Certificate?     Yes   No
Are you currently taking courses beyond high school?        Yes   No
Applicant Race/Ethnicity:*

American Indian and Alaskan Native (tribal affiliation of North, Central and South America)Asian (origins of Far East, Southeast Asia or Indian subcontinent)Black or African American (origins of any black racial groups of Africa)Hispanic or Latino (origins of Cuba, Mexico, Puerto Rico, South or Central America)Native Hawaiian and Other Pacific Islander (origins of Hawaii, Guam, Samoa, or Pacific Islands)Not Hispanic or Latino (origins of North America)White (origins of Europe, Middle East or North Africa)UnknownPrefer not to Disclose
What is your Limited English Proficiency Level:*

Proficient (Read/Speak)English Language LearnerLimited English Speaking AbilityLimited English Reading AbilityPrimary Language, if other than English:
BACKGROUND INFORMATION

If not applicable, please use "n/a" in appropriate fields.
Are you a United States citizen?   Yes   No*
Are you eligible to work in the United States?   Yes   No*
Have you been convicted of a felony or misdemeanor?    Yes   No*
If yes, please explain:
Have you been incarcerated within the last 6 months? Date released:   *
Are you currently on probation or parole?   Yes   No*
If yes, please explain:
Are you currently receiving FoodShare?   Yes   No*
Where you receiving Foodshare within the last 6 months?   Yes   No*
Are you currently in FSET (Foodshare employment program)?   Yes   No*
Where you receiving FSET within the last 6 months?   Yes   No*
Are you currently on State or local income-based assistance?   Yes   No*
Where you on State or local income-based assistance within the last 6 months?   Yes   No*
Are you currently on SSI (Supplemental Security Insurance)?   Yes   No*
Where you on SSI in the last 6 months?   Yes   No*
Are you currently in W2/ TANF?   Yes   No*
Where you in W2/TANF within in the last 6 months?   Yes   No*
If on W2/TANF, are you within 2 years of exhausting lifetime eligibility?      Yes   No*
Are you a migrant/seasonal farm worker?   Yes   No*
Are you a displaced homemaker?   Yes   No*
Are you a foster child receiving government support?   Yes   No*
Were you in foster care but have recently aged out of the system?   Yes   No*
Are you a non-custodial parent?   Yes   No*
Are you affected by substance abuse?   Yes   No*
Are you receiving alimony?   Yes   No*
Are you on the Free/Reduced lunch (applicant, not child)?    Yes   No*
Are you currently on Unemployment Insurance?   Yes   No*
If yes, what type:   UI Claimant    Exhaustee    Neither UI claimant nor exhaustee   UI but exempt from work search
Are you currently in the Trade Adjustment Assistance (TAA) program?   Yes   No*
Are you currently receiving a pension, retirement, or severance pay?   Yes   No*
Are you on Other Support?   Yes   No*
If yes, please list:
HOUSEHOLD INFORMATION

List the names, ages and relationship (self, son, daughter, niece, nephew, etc. of all persons living in your home, including yourself, and drivers license information, if applicable.
Your Information
Name:   First Name   Last Name
Age:   Number
Have a valid drivers license?
Drivers License #:
What state was it issued?
Expiration Date:
Current Employment Status:
# of Weeks Employed During the Last 26 Weeks:

Household Member 1
Name:   First Name   Last Name
Age:    Number
Relationship:
Have a valid drivers license?
Drivers License #:
What state was it issued?
Expiration Date:
Current Employment Status:
# of Weeks Employed During the Last 26 Weeks:

Household Member 2
Name:   First Name   Last Name
Age:    Number
Relationship:
Have a valid drivers license?
Drivers License #:
What state was it issued?
Expiration Date:
Current Employment Status:
# of Weeks Employed During the Last 26 Weeks:

Household Member 3
Name:   First Name   Last Name
Age:   Number
Relationship:
Have a valid drivers license?
Drivers License #:
What state was it issued?
Expiration Date:
Current Employment Status:
# of Weeks Employed During the Last 26 Weeks:

Household Member 4
Name:   First Name   Last Name
Age:   Number
Relationship:
Have a valid drivers license?
Drivers License #:
What state was it issued?
Expiration Date:
Current Employment Status:
# of Weeks Employed During the Last 26 Weeks:
Housing Status:*

RentOwnNeither, please explain:
Type of Home:*

HouseMobile HomeApartmentDuplexOther
What is your monthly rent/mortgage?*
How long have you lived there (include years and months)?*
VEHICLE/TRANSPORTATION INFORMATION (APPLICANT ONLY)
Do you currently own a vehicle?*

YesNo
Vehicle Year:
Make:
Model:
Miles on vehicle:
Estimated value of vehicle:
Is the vehicle registered in your name?

YesNo
Do you have loan obligations on the vehicle?*

YesNo
What is the unpaid loan amount (blance)?
Who is the loan payable to (name of bank/organization you make payments to)?
Do you have insurance on the vehicle?

YesNo
Nam of insurance company:
What type of vehicle coverage do you have?
Monthly insurance cost:
Do you have a license plate number?

NoYes, what is the license plate number:
License plate expiration date:
Licensing State (what state is it issued in):
If vehicle is not registered in your name list registrant name:
If this application is for a Vehicle Repair, describe condition and/or repair needs of current vehicle:
If this application is for a Vehicle Loan, describe what you plan to do with the vehicle you currently own:
If you do not currently own a vehicle, indicate method of transportation to and from work:
DRIVING HISTORY (APPLICANT ONLY)
Do you have any DUI, OWI, or alcohol related citations in past 5 years:*

NoYes, please explain:
Do you any moving violations in past 5 years:*

NoYes, please explain:
Do you have other criminal/civil convictions in past 5 years:*

NoYes, please explain:
EMPLOYMENT HISTORY (APPLICANT ONLY – BEGIN WITH CURRENT OR MOST RECENT EMPLOYER)
Employer Name 1 (current or most recent employer):
Company Name:      City:      State:
Job Title:      Wage:
Start Date:   Date   End Date:   Date
Reason for leaving:

Employer Name 2:
Company Name:      City:            State:
Job Title:            Wage:
Start Date:    Date        End Date:    Date
Reason for leaving:

Employer Name 3:
Company Name:      City:                  State:
Job Title:                  Wage:
Start Date:    Date              End Date:   Date
Reason for leaving:
REFERENCES

Please include a minimum of three (3) references below. You may include family members.
Reference 1
Name:   First Name*   Last Name*   Relationship:  *      Cell Phone:   Area Code*   Phone Number*   Email:   Email*

Reference 2
Name:   First Name*   Last Name*   Relationship:   *           Cell Phone:   Area Code*   Phone Number*           Email:    Email*

Reference 3
Name:   First Name*   Last Name*   Relationship:   *           Cell Phone:    Area Code*   Phone Number*           Email:     Email*
SIGNATURE (APPLICANT ONLY)
I/we certify that all information contained in this application is true and complete to the best of my/our knowledge and belief.
Signature:*

Clear
Today's Date:*

MonthDayYear
Date

MONTHLY FINANCIAL WORKSHEET

The following section is to gather income and monthly expenses to determine eligibility. Please note you will need to upload two (2) most recent paycheck stubs at the end of this application.
INCOME (APPLICANT ONLY)

If you will have a co-signer, please include their income under "Salary/Wage 2".
Your Salary or Wage Information
How often are you paid?
Gross Pay Per Paycheck (before taxes and deductions):
Net Per Paycheck (after taxes and deductions):

Co-Signer Information (if applicable)
How often paid?
Gross Pay Per Paycheck (before taxes and deductions):
Net Per Paycheck (after taxes and deductions):

Other Monthly Income (child support, alimony, SSI, etc.):
HOUSING EXPENSES
Monthly Rent/Mortgage Payment:
Monthly 2nd Mortgage/Home Equity Loan/Lot Rent:
Monthly Electricity/Heat (oil, gas, LP, wood):
Monthly Telephone/Cell Phone/Pager:
Monthly Cable/Satellite/Internet:
Monthly Water/Sewer/Trash:
Monthly Property Taxes (if not in mortgage escrow):
Monthly Homeowners Insurance/Renters Insurance:
Monthly Home Repair/Maintenance/Water Softener:
TRANSPORTATION EXPENSES
Monthly Car Payment #1:
Monthly Car Payment #2:
Monthly Auto Insurance:
Monthly Auto Maintenance Repair:
Annual License Tabs:
MISCELLANEOUS EXPENSES
Monthly Clothing Purchases (back to school/special trips):
Monthly Insurance (Health/Life):
Monthly Medical Expenses (copays/deductible/chiro/prescriptions):
Monthly Day Care/Pre-school/Private School:
Monthly Tuition/Supplies/Lessons:
Monthly Membership Fees/Health Club:
Monthly Income Taxes (payment plan/self-employed):
Monthly Union Dues/Investments/Savings/Bank Fees:
Monthly Gifts/Birthdays/Holidays/Parties:
Monthly Vacation/Travel:
Other Monthly Expenses:
FLEXIBLE EXPENSES
Gasoline (gas, taxi, ride-share, bus, parking):
Food (groceries, dining out, work lunches, school lunches):
Household Items (baby items paper products, laundry, clothes):
Cash/Miscellaneous (allowances, donations, tobacco, pet items):
Entertainment (baby sitters, movies, sports, hobbies, books):
Other:
CREDITOR EXPENSES
Name of Creditor 1:      Current Monthly Payment:      Remaining Balance:
Name of Creditor 2:      Current Monthly Payment:      Remaining Balance:
Name of Creditor 3:      Current Monthly Payment:      Remaining Balance:
Name of Creditor 4:      Current Monthly Payment:      Remaining Balance:
Name of Creditor 5:      Current Monthly Payment:      Remaining Balance:
Please Upload You Two (2) Most Recent Paycheck Stubs.*

Cancelof
Should be Empty:

Work 'n Wheels Application

NOTICE TO APPLICANTS

APPLICANT DEMOGRAPHICS

BACKGROUND INFORMATION

HOUSEHOLD INFORMATION

VEHICLE/TRANSPORTATION INFORMATION (APPLICANT ONLY)

DRIVING HISTORY (APPLICANT ONLY)

EMPLOYMENT HISTORY (APPLICANT ONLY – BEGIN WITH CURRENT OR MOST RECENT EMPLOYER)

REFERENCES

SIGNATURE (APPLICANT ONLY)

MONTHLY FINANCIAL WORKSHEET

INCOME (APPLICANT ONLY)

HOUSING EXPENSES

TRANSPORTATION EXPENSES

MISCELLANEOUS EXPENSES

FLEXIBLE EXPENSES

CREDITOR EXPENSES