Client - Gap Application

Name(Required)

First Middle Last

Phone(Required)

Email(Required)

Gender(Required)

Male

Female

Are you still in need of assistance?(Required)

Yes

No

Which volunteer have you been communicating with over email?(Required)

Make sure you double-check what you select here, as this form will be sent to them upon completion.

What kind of assistance are you applying for?(Required)

Service

Car

Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

At this time, are you married, single, divorced, widowed, separated, common law husband or have a live-in significant other?(Required)

If you answered other, please explain:(Required)

Has your divorce been finalized?(Required)

Yes

No

Divorce Decree(Required)

Max. file size: 100 MB.

Who lives in your household?(Required)

Are there any other adults living with you?(Required)

Yes

No

If yes, what are their names, ages and your relationship to them?(Required)

Are you, and/or any of your children living in your home, disabled or ill?(Required)

Yes

No

Please go more into detail on what disabilities or illnesses you and/or your children have:(Required)

Do you receive any local support? (Husband, parents, siblings, grandparents, etc.)(Required)

Yes

No

If so, what kind? Explain.(Required)

Do you have dependent children living in your household?(Required)

Yes

No

If so, list their names, age, and gender.(Required)

How does your child get to school?(Required)

What is your income? (wages, state benefits, child support, etc)(Required)

Do you work?(Required)

Yes

No

Where do you work?(Required)

Who is your immediate supervisor?(Required)

Name and contact information preferred.

Do you attend college or trade school?(Required)

Yes

No

If you attend college or trade school, where?(Required)

Do you have a valid driver's license?(Required)

Yes

No

Upload a copy of your driver's license below(Required)

Drop files here or

Max. file size: 100 MB.

Drivers License State(Required)

KY, TX, IL, IN, etc..

Date of Birth(Required)

Last 4 of your SSN (Social Security Number)(Required)

VIN(Required)

The VIN of the vehicle you need repairs for.

Year of your vehicle(Required)

The year of the vehicle you need repairs for.

Make of your vehicle(Required)

The make of the vehicle you need repairs for.

Model of your vehicle(Required)

The model of the vehicle you need repairs for.

Vehicle registration and Insurance for your vehicle(Required)

Drop files here or

Max. file size: 100 MB.

Photocopy or scanned documents allowed

What is wrong with your vehicle?(Required)

Please share your story with us. Why do you need a car?(Required)

Please share your story with us. Why do you need a car repair?(Required)

Finances

Monthly Income ($):(Required)

Other Income ($):

If you provided other income, what is this income from?(Required)

Type NA if none.

Child Support You Receive ($):(Required)

Any Disability Income ($):(Required)

Food Stamps You Receive ($):(Required)

Total Monthly Income:

Expenses

Rent / Mortgage ($):(Required)

Utilities ($):(Required)

Phone ($):(Required)

Internet ($):(Required)

Streaming Services ($):(Required)

Credit Card Payments ($):(Required)

Any Other Expenses ($):

Other Expense Details:(Required)

Any Other Expenses (2) ($):

Other Expense Details:(Required)

Any Other Expenses (3) ($):

Other Expense Details:(Required)

Total Monthly Expenses:

Net Result

Total Surplus or Deficit:

If you are given a car or receive repairs to your vehicle, how do you plan to pay for maintenance, insurance and other monthly expenses going forward?(Required)

What is the biggest question you have about saving money or managing your finances?(Required)