*** To be considered for a vehicle, all qualifications must be met and the application must be filled out completely

Thank you for your interest in the Good News Garage JumpStart Program. This program is available for qualified applicants who are currently employed o...
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Thank you for your interest in the Good News Garage JumpStart Program. This program is available for qualified applicants who are currently employed or have a verifiable job offer and meet the income requirements (see attached). We recommend that you review the JumpStart overview and qualifications prior to completing and submitting application. To be considered for a vehicle, all conditions must be met and the application must be complete. Please complete the application and return it to your local Good News Garage office: New Hampshire and Massachusetts residents: Attn: Amber Raby 340 Granite Street, 3rd Floor Manchester, NH 03102 Phone: 603.669.6937 Fax: 603.626.7763 Email: [email protected] Vermont residents: Attn: Eva St. Andrews 331 North Winooski Avenue Burlington, VT 05401 Phone: 802.864.3667 Fax: 802.864.6033 Email: [email protected] In addition to your completed application, you must include the following with your application: Copies of your and any other adults in the household driver’s license Copies of recent pay stubs for the previous month. Include pay stubs for all jobs and all adults in the household After reviewing your application if we determine that we are unable to help you, you will be notified.

*** To be considered for a vehicle, all qualifications must be met and the application must be filled out completely. We receive many more inquiries for cars than we have cars to place. If you are approved it could be several months before a car becomes available. Failure to complete the application in a thorough manner will prolong the application process or potentially disqualify the applicant.

Agreement to Rules and Regulations of the Good News Garage JumpStart Vehicle Program

I, _________________________________ of (town, state) ___________________________________ hereby acknowledge and agree to the following: (please initial each box) 1.

I understand that JumpStart cars are donated vehicles that undergo a 72-point safety check by certified mechanics and licensed garages. I understand that certified mechanics employed by licensed garages made all necessary repairs for the current day plus any foreseeable necessities.

2.

I acknowledge that any and all repairs made to the vehicle are strictly for functionality and safety reasons. I understand that cosmetic repairs (including but not limited to: dents, radios, sun roofs, air conditioning or interior wear) are not included by Good News Garage.

3.

I understand that the high quality and sustainability of the vehicle has been determined by a certified mechanic at a licensed garage and Good News Garage’s experienced Vehicle Processor. Regardless of age or mileage, the car has been deemed safe and reliable by a certified mechanic in a licensed garage.

4.

I understand that I will be offered a vehicle and given a maximum of three business days to decide upon the offer. I understand that if I neglect to inform Good News Garage of a decision within three business days, it will be considered a rejected offer.

5.

I understand that I will be required to pay a processing fee ($250 - $500 on a sliding scale) and all additional fees including insurance (in MA and VT), taxes and registration and that the vehicle will come with all necessary repairs and a limited warranty of 30 days or 1,200 miles, whichever comes first.

I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THE AGREEMENT TO RULES AND REGULATIONS AND THAT I ACCEPT AND AGREE TO ITS TERMS. I ATTEST THAT ALL INFORMATION PROVIDED IS TRUE AND ACCURATE.

SIGNED AND AGREED TO, _________________________________ __________________________________ ______________ Print Name Signature Date

JumpStart Vehicle Program Application Date: ___________________ Name: ____________________________________________________________________________________ Address: __________________________________________________________________________________ City: _____________________________________ State: __________ Zip: ____________________________ Day Phone: ________________ Night Phone: _______________ Cell Phone: ________________________ Email Address: __________________________________________________ Driver’s License Number: _____________________________ Birthdate: ______________________________ Work location: ______________________________________________________________________________ Number of hours working per week (for your all jobs): ___________________________________________ Household size: Number of Adults _______ Number of Children _______ Ages: _____________________ If second adult in the house: Name: ____________________________________________________________________________________ Driver’s License Number: _____________________________ Birthdate: ______________________________ Work location: _______________________________________________________________________________ Number of hours working per week (for all jobs):__________________________ Check the following that apply to you, I can drive: ____ Automatic transmission only ____ Standard Transmission (stick shift with clutch) ____ Both Do you have a preference for what type of vehicle you would like: sedan, van, SUV, pick-up, etc.? (We can’t guarantee that we can meet your preference.) ________________________________________________________________________________________ Do you currently have a car registered or insured in your name?

Yes

No

If you currently have a car registered in your name, please fill out the Vehicle Condition Form on page 8. Do you know of any outstanding taxes, insurance obligations or DMV issues that would prevent you from registering a car and obtaining auto insurance? Yes

No

If yes, please explain. Note: Good News Garage completes thorough DMV checks on all applications. Applications with outstanding taxes, insurance compliance issues, or current driving violation cases will be disqualified until such matters are resolved. _________________________________________________________________________________________ _______________________________________________________________________________________

Please explain how receiving a JumpStart vehicle will assist you and your family (feel free to handwrite or attached a typed document if preferred): _________________________________________________________________________________________

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_________________________________________________________________________________________ If there is more information which you feel is relevant towards you obtaining a JumpStart car or repairs, please explain on another sheet of paper. I certify that all of the information above is true and verifiable. I understand that to participate in this program application information may be verified by or discussed with other agencies, employers, caseworkers and/or references. I give Good News Garage permission to do so, if necessary. APPLICANT SIGNATURE: __________________________________________Date ______/______/_______

Budget Worksheet Name: _____________________________________________________ Date: ____________________ * Please attach copies of all pay stubs for one month for each adult in the household. This budget must be completed honestly and completely. Incomplete budgets will prolong the application process. This information is used to determine applicant’s ability to afford and maintain a vehicle.

Number of Dependents:

___________

Total Household size: ___________

Household Monthly Income: Employment (gross monthly) Child Support Monthly Assistance Received Section 8 or Assistance with Rent/Mortgage Utility Assistance (Electricity/Water/Heat) Food Stamps, “SNAP” Child Care Assistance Other (TFA, 2nd job) ___________________

$___________ $___________ $___________ $___________ $___________ $___________ $___________

TOTAL INCOME INCLUDING ASSISTANCE

$___________

Monthly Expenses Rent or Mortgage Payment Student Loans/Tuition Heat Electric Water/Sewer Telephone Cell Phone Cable TV and/or Internet Groceries (food, toiletries, diapers) Clothing (average family need per month including diapers) Medical Expenses Child Support Payments Child Care Cost Credit Card Payments Laundry Spending Money (cigarettes, coffee, candy, nails & hair, etc.) Entertainment (movies, dining out, magazines, etc.) Bus/Taxis/Other Transportation Miscellaneous/Other Car Insurance (Estimate: $65 - $100 per month) Car Gas (per month) Savings toward car repairs, annual registration, other fees

$_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $______55_____

TOTAL EXPENSES

$_____________

BALANCE (income minus expenses)

$_____________

If you’d like to include any additional information to explain your budget: _________________________________________________________________________________________

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Commuting Worksheet Please describe your current commute to work. If your situation requires travel to multiple sites (job, school, childcare, etc.), please include this information. Document your most challenging/difficult days. My home address: _______________________________________________________________

My work address is: _______________________________________________________

My childcare address is: ____________________________________________________________ I begin my commute at (time) _____:_____ am / pm. I commute TO work by (check all that applies): _______ WALKING ______ BUS

_________ TAXI ________ OTHER (carpool, family member, bike, etc.)

I arrive at work by (time) ____:____ am / pm I leave work at (time) ____:____ am / pm I commute FROM work by (check all that applies): _______WALKING _______BUS _________TAXI ________OTHER (carpool, family member, bike, etc.) I arrive home at (time) ______:______ am / pm Include any additional commuting information you’d like to share: _________________________________________________________________________________________

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Applicant name (print): ___________________________________________________

Signature: ________________________________ Date: ____ / ____ / ____

Vehicle Condition Report If you have a car currently registered in your name, complete this page. To qualify for a vehicle, we must verify the status of your current vehicle. Applicant name: ___________________________________ Phone number: ____________________ Email address: __________________________________ Address/City/State/Zip: _________________________________________________________________ Vehicle Year/Make/Model:________________________________________ Mileage: _____________ Vin #: _______________________________________ Is the vehicle registered?

Yes

Is there a valid title for this vehicle?

No

Yes

No

Is the vehicle insured? Yes

No

Has your vehicle passed inspection within the last year? Yes No If not, please explain: _________________________________________________________________________________________ Do you feel this vehicle is safe to drive? Yes No If not, please explain: _________________________________________________________________________________________ Is the car currently being driven?

Yes

No

*This section to be completed by certified mechanic: Name of garage: ______________________________ Mechanic: ____________________________________ Garage address: ______________________________________________________________________________ Garage phone: _______________________

Inspection facility #:_______ ____________________________

Describe body condition of vehicle: ______________________________________________________________ ____________________________________________________________________________________________ Describe necessary vehicle repairs: _______________________________________________________________ ____________________________________________________________________________________________ Based on my evaluation, it is my opinion that this vehicle (check one): Is NOT worth repairing ________

IS worth repairing ________ (please attach written estimate)

Signature of mechanic: ___________________________________ Date: _____/_____/_______

Sponsorship Form Good News Garage (GoodNewsGarage.org) is a “Wheels to Work” car donation program that provides vehicles to working individuals or those with a verifiable job offer. All vehicles awarded have been donated, and we provide vehicles to residents in New Hampshire, Massachusetts and Vermont. Every application for a JumpStart vehicle must include a “sponsor” who can validate the individual’s situation. You have been asked to serve as a sponsor for the individual below. To process this application, we request that you complete and return this information in a timely manner. If you have any questions, please contact us. Thank you! Date:

___________________ Applicant name:______________________________________________

Sponsor name:___________________________________________________________________________ Sponsor address: _________________________________________________________________________ City: _____________________________________ State: __________ Zip: _________________________ Day phone: ________________ Night phone: _______________ Cell phone: _________________________ Email address: __________________________________________________ Your current position or relationship to applicant (cannot be a relative): ________________________________________________________________________________________ I have known the applicant for __________ months or ______________ years I know the applicant in the following ways (please describe all): _________________________________________________________________________________________ _________________________________________________________________________________________ Briefly describe how or why the individual named above would benefit by receiving vehicle assistance from Good News Garage (handwrite below or type and attach a statement): _________________________________________________________________________________________ _________________________________________________________________________________________

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_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Sponsor name (print): ___________________________________________________

Sponsor signature: ________________________________ Date: ____ / ____ / ____

Please return completed form to: New Hampshire or Massachusetts applicants: Good News Garage Attn: Amber Raby 340 Granite Street, 3rd Floor. Manchester, NH 03102 Phone: 603.669.6937 Fax: 603.626.7763 Email: [email protected]

Vermont applicants: Good News Garage Attn: Eva St. Andrews 331 North Winooski Avenue Burlington, VT 05401 Phone: 802.864.3667 Fax: 802.864.6033 Email: [email protected]

General Media Consent Form Good News Garage is a member of Ascentria Care Alliance. Ascentria and its subsidiaries have my permission to use my photograph, likeness, artwork, profile and/or story in all forms of media and all manners, including publications, web pages, video, interactive and social media, and other promotional materials. I understand the circulation of the materials could be worldwide and that there will be no compensation to me for this use. I waive any right to inspect or approve the finished product, including written copy that may be created in connection therewith. Furthermore, I hereby release in perpetuity Ascentria, its board members, leadership, agents, contractors, volunteers and employees from any and all claims, actions, demands, suits, liabilities, causes of action of whatsoever character, in connection with the use of these materials. Ascentria may use my: __ first name only

__ first and last name __ I wish to remain anonymous.

My signature below confirms my understanding, agreement and consent to the above statements. Print name: ________________________________________________________________________ Email: ______________________________________________ Phone: _______________________ Signature: ________________________________________________________ Date: ___________ Parent/guardian name: ______________________________________________ (If under 18 or required)

Parent/guardian signature: ___________________________________________ Date: ___________ Please contact the Ascentria Strategic Marketing and Communications department with any questions or concerns at 774.243.3900 or [email protected] I understand that I have the right to withdraw my consent at any time with a written request sent to: Ascentria Care Alliance, Strategic Marketing and Communications Department, 14 East Worcester Street, Suite 300, Worcester, MA 01604. Staff Use Only Staff / Location: ____________________________________________________________________ File types: __ Image __ Video __ Audio __ Transcript __ Testimonial File(s) storage location: _______________________________________________________________ Notes: _____________________________________________________________________________ __________________________________________________________________________________

Income Guidelines for JumpStart To qualify for JumpStart your Household Income can't exceed 200% of the Federal Poverty Guidelines for FY2016

Size of family unit

200% of Poverty

1 2 3 4 5 6 7 8

$23,540 $31,860 $40,180 $48,500 $56,820 $65,140 $73,460 $81,780

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