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Request for Application Support - Driving Clean Assistance Program
Thank you for your interest in the Driving Clean Assistance Program (DCAP) for Placer County. Please fill out the following survey if you are interested in receiving application support from a Health Education Council (HEC) staff member. After you've completed the survey, an HEC staff member will call you to share the next steps and help schedule an appointment for application support. If you have any questions in the meantime, you can call us at (916) 556-3344 or email us at econ_wellbeing@healthedcouncil.org. If you would like to learn more about the program, please visit drivingcleanca.org.
Name (First & Last)
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current residential address or zip code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you participated in and received assistance from any of the following programs in the past? (Please check all that apply). If you've participated or received assistance from any of the programs listed, you will not be eligible for DCAP, and the survey will end.
*
Clean Vehicle Rebate Project
Clean Vehicle Assistance Program
Bay Area Regional Driving Clean Assistance Program
Clean Cars 4 All
None
Unsure
How many individuals live in your household?
*
What is the household annual income?
*
If your current address does not match the address on your driver's license, select which other documents you can provide to verify your current address (must select at least two). Driver's license is required for all applicants.
*
My driver's license includes my current address
Official documents with current address (W2, DMV documents, tax return, etc.)
Utility bills
Bank statement
Mortgage/rental statement
Select which of the following documents you have available to verify income (must select at least one).
*
Tax documents from the previous year (copy of tax return or summary)
Two of the most recent pay stubs
Award letter for Social Security Income (SSI) or Social Security Disability Income (SSDI)
Other award letter (unemployment, pension, Veteran Affairs benefits, etc.)
Two most recent bank statements
Do you currently own a vehicle? You may be eligible to scrap your vehicle to receive additional benefits (only eligible if you own a gas or diesel powered vehicle, model year 2010 or older) (optional)
Yes
No
Unsure
Please let us know your general availability (select all that apply)
Mondays 8am-12pm
Mondays 12pm-5pm
Tuesdays 8am-12pm
Tuesdays 12pm-5pm
Wednesdays 8am-12pm
Wednesdays 12pm-5pm
Thursdays 8am-12pm
Thursdays 12pm-5pm
Fridays 8am-12pm
Fridays 12pm-5pm
Other
How did you hear about the Driving Clean Assistance Program (DCAP)? Select all that apply
Social Media
Community Events
Food Distributions
Word of Mouth
Other
Submit
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