Thank you for your interest in the Good News Garage JumpStart Program. This program is available for
qualified applicants who are Vermont residents and 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:
Good News Garage
Attn: JumpStart
331 North Winooski Avenue
Burlington, VT 05401
Phone: 802.864.3667
Fax: 802.864.6033
Email: info@goodnewsgarage.org
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.
8-10-16
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, 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 name and 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 name and 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 or anyone in your household 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):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Sponsor name (print): ___________________________________________________
Sponsor signature: ________________________________ Date: ____ / ____ / ____
Please return completed form to:
Good News Garage
Attn: JumpStart
331 North Winooski Avenue
Burlington, VT 05401
Phone: 802.864.3667 Fax: 802.864.6033
Email: info@goodnewsgarage.org
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 info@ascentria.org.
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