Assistance Application
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Phone Number
*
Email Address
*
Preferred Contact Method (Phone, Email)
*
Best Days/Times to Contact
*
Have you previously received assistance from Worthy of Wheels? If yes, when?
*
Drivers License Info
A valid and active drivers license is required for assistance approval.
Drivers License Number
*
Drivers License State
*
Drivers License Expiration Date
*
-
Month
-
Day
Year
Household Information
Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How long have you lived at the above address?
*
Household size (number of people dependent on applicant)
*
Marital Status
*
Primary source of income (employed / self-employed / retired / disabled / unemployed)
*
Annual Household Income
*
Before Taxes
Monthly Rent/Mortgage Payment
*
Are you currently receiving any government assistance? (If yes, please explain)
*
Any outstanding debts related to vehicles/transportation? (If yes, please explain)
*
Vehicle Information
Year
*
Make
*
Model
*
VIN
*
Current Mileage
*
Drivable? (Yes / No - Please explain)
*
Currently registered? (Yes / No - Please Explain)
*
Currently insured? (Yes / No - Please Explain)
*
Current vehicle & driver insurance is required for assistance approval.
Vehicle Condition
*
Reason for Assistance
Statement of Need - Please describe why assistance with your vehicle is needed at this time.
*
(Example: lost job, medical needs, recent breakdown, no reliable transportation for work, etc.)
Do you have a second vehicle available?” (If yes, please explain)
*
Weekly driving needs
*
How many miles do you drive per week for work/school/medical?
What does lack of reliable transportation currently affect?
*
Employment
Medical Appointments
Childcare/school
Religious Involvement
General Daily Needs
How soon will this situation cause serious hardship if unresolved?
*
Already Occurring
Within 1 week
Within 30 days
Longer-term issue
Unsure
Supporting Documents
Proof of income (pay stubs, tax return, etc.)
*
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Proof of Vehicle Ownership (Title or Equivalent)
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Application can be submitted without current registration, but will be required before funding approval
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Proof of Insurance
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Application can be submitted without current insurance, but will be required before funding approval
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of
Drivers License (front & back)
*
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Valid Drivers License is required for assistance approval
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of
Photos of vehicle condition (4 corners + interior + close-ups of problem area if visible)
*
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Vehicle Repair Estimate/Diagnosis (if available, not required)
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Referral Source
*
How did you hear about Worthy of Wheels?
Consent & Authorization
Consent to verify income/household info - I authorize Worthy of Wheels to verify the information provided.
*
Yes
Consent to communicate by email/phone - I consent to receive communications regarding my application and updates about services.
*
Yes
I understand that submitting this application does not guarantee assistance and that Worthy of Wheels may be unable to help due to funding or eligibility limits.
*
Yes
I authorize Worthy of Wheels to share my application information with partner churches, organizations, volunteers, or repair facilities as necessary to verify information, evaluate eligibility, or fulfill assistance.
*
Yes
I understand Worthy of Wheels determines whether repair or replacement is appropriate, and replacement is not guaranteed.
*
Yes
I certify that the information provided is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of assistance or disqualification from future programs.
*
Yes
I acknowledge and agree to the Media, Likeness, and Testimonial Release below.
*
Yes
Media, Likeness, and Testimonial Release
I grant Worthy of Wheels permission to photograph, video record, audio record, or otherwise capture my image, likeness, voice, vehicle, and/or written or verbal statements in connection with assistance provided by the organization. I understand and agree that these materials may be used by Worthy of Wheels for nonprofit purposes, including but not limited to promotional materials, website content, social media, fundraising, educational efforts, and community outreach, without compensation. I understand that my participation in these materials may include, but is not limited to, photographs with my vehicle, written testimonials, or recorded interviews. I acknowledge that Worthy of Wheels may edit, reproduce, distribute, and display these materials in any format or medium consistent with its nonprofit mission. I understand that submitting this application constitutes my consent to this release, and that agreement to this release is a condition of receiving assistance from Worthy of Wheels.
Signature
Please verify that you are human
*
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