Tier II Program
Individuals wanting to purchase a car through this program must meet the following qualifications:
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You must have a verifiable job offer or be working at least 30 hours a week. If enrolled full time in a
post-secondary education program (i.e. 9 or more credit hours) you must work a minimum of 25 hours
per week. Must provide proof of full time enrollment.
You must have a driver’s license in the state in which you reside
You must be insurable (no DWIs or DUIs)
You must not have any other vehicle in your household
You must be drug free and have no extensive criminal background
You must be able to pay for your insurance, and the ongoing expense of fuel and car maintenance.
You must be able to cover fees for taxes, tags and title (approximately an additional $500).
If you are under the age of 25, you must have children
You must meet the income requirements listed below
Must attend the VFC Car Orientation Program, prior to receiving your vehicle
The cars provided in this program are generally divided into two categories:
1. Older models start at $1,100. Price includes a 30 day/1,000 mile power train warranty. AAA is optional
with the additional cost due at purchase.
2. Cars produced from 1997 to 2003. Prices begin at $2,000, and include a 6-month/6,000 mile limited
warranty.
A loan is not offered for this program so if you are not able to pay the full price in one lump
sum, you must be able to obtain your own loan before you submit an application. Anyone
wishing to apply for a car through the Tier II program must complete this application.
Please make sure all required documents are submitted at the time the application is sent or
the application will not be processed. See page 9 for required documents.
Check the website at http://vehiclesforchange.org, or email tmcfadden@vehiclesforchange.org for more
information.
Income Guidelines
Number of Persons in Household
1
2
3
4
5
6
Maximum Income Level
$25,000
$37,400
$47,000
$56,500
$66,000
$75,600
Please send completed packet to:
Vehicles For Change
5230 Washington Blvd.
Halethorpe, MD 21227
Attn: Ms. McFadden
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Vehicles For Change, Inc.
APPLICANT DATA
Name of Applicant: ______________________________________________________________
Address: _______________________________________________________________________
Street
City
State
Zip
Home Phone: _______________________ Work Phone: ________________________________
Cell Phone: ________________________ Email Address: _______________________________
S.S. # _____________________________ Driver’s License: _____________________________
Are you licensed to drive? __ Yes __ No
Can you drive a motor vehicle? __ Yes __ No
Can you drive a stick shift? ___ Yes ___ No
Are there others in your household licensed to drive? __ Yes __ No
If yes, Name and relationship: _______________________________________________________________
Name
HOUSEHOLD MEMBERS (including applicant)
Relationship to applicant Social Security Number
Date of Birth
SELF
If additional space is needed for family members, please use the back of this page.
NOTE: Per Maryland Law Every child under 6 years old, regardless of weight, and every child weighing 40 pounds or less,
regardless of age, must be secured in a U.S. DOT approved child safety seat. Children and young people up to 16 years of age must be
secured in seat belts or child safety seats, regardless of their seating positions. It is strongly recommended that all children ride secured
in the rear seat. Drivers and front seat passengers, regardless of their ages, are required to wear seat belts. It is strongly recommended
that all occupants wear seat belts.
Number of children not living in your home: ___
Are any of your children in day care? __ Yes __ No
Ages: __________________________________
How many? ___ Hours: ____________________
Do any household members own a car, van or truck? __ Yes __ No
If yes, name of person: ___________________________________________________________________
Do you have access to this vehicle? __ Yes __ No
If relevant to your application, list any family members who are disabled. Give disability. (You will be required to submit
medical documentation of this disability if selected.) _______________________________________________________
How much money will you have to spend on a vehicle if your application is approved? $ _________
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Vehicles For Change, Inc.
HOUSEHOLD INCOME AND EXPENSES
Your income and expense information must be completed accurately. Applicants should complete this part of the application with
someone from the sponsoring agency (if applicable). Items below are on a monthly basis.
Take Home Wages/Salary (after taxes)
$___________
(If you are paid weekly take the earnings amount a multiple it by 52 and then divide by 12; if you are paid by-weekly, multiply your
check by 26 and divide by 12)
Child Support
(Only include if you are sure to receive it every month)
$____________
Food Stamps
$____________
TANF or other State support
$____________
(Only include if you will receive for at least 9 more months)
SSI (amount of monthly check)
$____________
Other Income (list on lines below)
______________________
$____________
______________________
$____________
TOTAL OF ALL INCOME LISTED ABOVE
$_____________
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Vehicles For Change, Inc.
Budget Sheet
Housing Costs
Mortgage/Rent
$____________
House Repairs
$____________
Insurance
$____________
Total Housing
$__________
Utilities (Monthly Bills)
Gas and Electric
$____________
Water
$____________
(if your water bill comes every 3 months divide by 3)
Phone (include cell)
$____________
Total Utilities
$__________
Child Care and School Expenses
Monthly Childcare Fees $____________
School Materials
$____________
Other
$____________
Total Child Care and School Expenses
$___________
Medical Expenses (you will need to determine or estimate Medical on a monthly basis)
Doctor Visits
$____________
Dentists
$____________
Prescriptions
$____________
Eye
$____________
Total Medical Expenses
$___________
Transportation
Car ownership
$____________
Car Insurance
$____________
Gas
$____________
Car Repairs
$____________
Monthly Cab or Bus Fare
$____________
Ride Payments to Friends
$____________
Total Transportation
$___________
Gifts (you will have to divide the amount by 12 to get your monthly costs)
Christmas
$____________
Birthday
$____________
Other
$____________
Total Gifts
$____________
Food - Meals and Groceries – Including Food and Non-Food Items
(if you receive food stamps, this must be equivalent to the amount received and listed above)
Lunches
$___________
Spending on Dinners Out
Groceries
$___________
$___________
Groceries should include: Cleaning supplies, household items, toiletries, cosmetics, cigarettes
Total Food
Clothing (include shoes, coats etc. : estimate monthly cost for yourself and family)
Total Clothing
$____________
$____________
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Vehicles For Change, Inc.
Entertainment/Recreation
Cable or Dish
DVD rentals
Vacations (divide total by 12)
Other
Total Entertainment
$__________
$__________
$__________
$__________
$____________
Total Expenses (add all the above items in the last column)
$____________
Available Monthly Funds (income minus expenses)
$____________
Have you received Cash Assistance or other benefits in the past 24 months? (Food stamps, medical assistance, POC etc.)
____Yes ____No
For how many months? _______ From which agency? ____________________________
Money in Savings Account or Other Savings
$____________
Note: You will need at least $1,500.00 in savings for the cost of the car and taxes, tags and title fees.
Demographical Information
Please provide the following information which will be used by authorized personnel for statistical purposes
only. This data will not impact the selection process. Vehicles For Change, Inc. does not discriminate
based on race, sex, religion or national origin.
Race (please check one only):
Household Status:
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__
__
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__
__ Single, male head of household
__ Single, female head of household
__ Two adult household
White, non-Hispanic
Black, non-Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native
Hispanic
Other ________________________
Income Guidelines
NOTE: The income is annual and before taxes (Gross Amount). If more than one adult lives in the household you must
include their income as well.
YOUR HOUSEHOLD ANNUAL INCOME
Other Income - Child Care, Food Stamps etc.
Income of Other Individuals in the House
$_____________
$_____________
$_____________
Total Household Income:
$_____________
Total Number of Persons in Household:
$_____________
Your maximum income level (see chart on page 1)
$_____________
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Vehicles For Change, Inc.
EMPLOYMENT
Are you currently employed? __ Yes __ No
Hours: Begin ________ am/pm
Number of hours per week? _________________
End: ________ am/pm
Shift ___ 1st ___ 2nd ___ 3rd
Current Employer: ______________________________________________________________________
Address: ______________________________________________________________________________
Contact Person: _____________________________ Phone: ____________________________________
How long have you been employed there? ________________ Position: __________________________
List your last three employers, your position with that employer, and the dates of the employment:
1. ___________________________________________________________________________________
___________________________________________________________________________________
2. ___________________________________________________________________________________
___________________________________________________________________________________
3. ___________________________________________________________________________________
___________________________________________________________________________________
If you are not currently employed, do you have a verifiable job offer? __ Yes __ No
If yes, please list the following:
Employer: ____________________________________________________________________________
Address: _____________________________________________________________________________
Contact Person: _____________________________ Position: __________________________________
How are you getting to work now? _________________________________________________________
How will a car allow you to become/remain self-sufficient and improve your life? You may use back of this page to write
yourresponse._______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________PLEASE NOTE: Distribution of cars to eligible applicants depends on the availability of cars. From
the submission of your application to the receipt of your car, the process may take from one to six weeks.
Please be patient. Applicants/Sponsoring agencies will be advised as to the status of the application as they
move through the process. Completion of this application does not guarantee that you will receive a car.
Please verify all information is complete prior to submitting. You will not be
contacted for additional information. INCOMPLETE APPLICATIONS
WILL NOT BE PROCESSES.
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Professional Reference
To be completed by Sponsoring Agency, Employer, or Church Official.
Sponsoring Agency/Employer/Church Official: ________________________________________
Phone:
________________________________
Mailing Address:
_____________________________________________________
___________________________________________
Contact:
_________________________________
E-Mail:
__________________________
Fax: _______________________
Why would the applicant be a good candidate for a car from Vehicles For Change, Inc.? Please
explain____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Explain any extenuating circumstances:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of Reference: ______________________________________
Date: _________________________________
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Vehicles For Change, Inc.
Photographic Consent Form
Vehicles For Change may be interested in sharing your story with others via newsletters, email, fliers,
postcards, media, etc. Sharing this information will allow Vehicles For Change to continue its mission to assist
families in achieving financial and personal independence. Stories and photos encourage people to donate their
vehicles, which allows VFC to assist more families.
If you agree to allow VFC to use your photo/story, please complete Section A. If you prefer that we refrain from
publishing your photo/story, please complete Section B.
Section A:
The undersigned does hereby authorize VEHICLES FOR CHANGE and/or its associates, assistants, or
subcontractors to photograph/film
_____________________________________________.
Name (please print)
The undersigned authorizes Vehicles for Change to permit the use and display of said photographs for use in
any publication, multimedia production, display, advertisement or World-Wide Web Publication.
The undersigned agrees that Vehicles for Change may use name, likeness, or biographical information supplied
by the undersigned.
The undersigned releases and forever discharges Vehicles for Change and its employees from any and all claims
and demands arising out of or in connection with the use of said photographs / images, including but not limited
to, any claims for invasion of privacy or defamation.
Accepted and Agreed:
__________________________________________________________________________________________
Signature of Subject
Signature of VFC Witness
__________________________________________________________________________________________
Date
Date
Section B:
I do not wish to have my story or photograph utilized in any production to further the mission of Vehicles for
Change.
__________________________________________________________________________________________
Signature of Subject
Printed Name of Subject
Date
__________________________________________________________________________________________
Signature of VFC Witness
Printed Name of Witness
Date
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Vehicles For Change, Inc.
**Submit With Your Application**
1. A copy of the applicants and all household members’ social security card.
2. A copy of a valid Maryland, D.C. or Virginia drivers license for all eligible people in
your household.
3. Proof of income (most recent three paystubs) or letter from employer on company
letterhead stating income and hours to be worked.
4. Three-year driving record (to be reviewed for insurability) for everyone who is licensed
to drive in your household.
5. Registration record, if Maryland resident, to assure that no insurance violations or
other flags exists.
Maryland residents must use MVA form DR-057 (sample attached) to secure driving and
registration records. Submit reports with application.
Read Carefully and Sign Below
I have read the requirements as outlined on page one of this application and I meet each of the requirements
necessary to qualify for a car from Vehicles for Change, Inc.
The information provided by me in this application is true and complete to the best of my knowledge. I
understand that misrepresentation or omission of facts called for is cause for the rejection of this application.
Further I understand and agree that evaluation of this application does not guarantee a car from Vehicles
for Change, Inc.
I hereby provide permission to the Department of Social Services or
sponsoring agency to release any information to Vehicles for Change
pertaining to my address, phone, work and/or name. I also provide the
Department of Social Services with permission to update Vehicles for
Change on any changes or sponsoring agency to this information until my
automobile loan is paid in full.
Signature of Applicant(s)________________________________________________
Date_______________
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Vehicles For Change, Inc.
Customer Agreement
As a customer of a car from Vehicles For Change, Inc., I understand that I must fulfill the following
responsibilities:
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Maintain my car with regular maintenance including tune-ups, oil changes and other normal
maintenance procedures. The procedures are designed to reduce the chance of major mechanical
problems and prolong the life of the car.
Attend the 2-hour Car Maintenance class as scheduled in the “Process for Obtaining a Car.”
Contact VFC at 1-800-835-3821 prior to having any repairs completed. Vehicles for Change, Inc.
provides me with a limited warranty on my car. We do not pay for repairs that have not been authorized
by VFC. Transportation of the car to the VFC garage is the customer’s responsibility.
Make arrangements for transportation on your own while your car is being serviced.VFC does not
provide a loaner car during this time, nor do we pay for rental cars.
Vehicles For Change, Inc. will not pay for any damages caused by collision, vandalism, negligence or faulty
operation or maintenance. Negligence includes driving the car after the temperature gauge and/or warning
light has registered “HOT.” This will result in extreme damage to the engine and it can only occur through
driver negligence. In addition, we will not pay for any repairs of a car if loan payments are not current. Please
note that Vehicles For Change, Inc. does not repair or warranty the air conditioning or the radio in any car.
The garages repairing VFC cars are very busy and perform repairs for VFC at a substantial discount. It is very
important that you keep all appointments for repairs. If an appointment is made with the garage to repair your
car under the warranty and you miss your appointment without first contacting the garage, VFC will not pay
the cost of that repair. VFC will not honor any warranty repairs that cannot be completed at a VFC-designated
garage.
I understand that it is the goal of Vehicles For Change, Inc. to provide me with reliable transportation so that I
may help myself become financially secure. The car I receive may be 7 – 15 years old and may have over
125,000 miles. The car may have some minor problems. These will not affect the safety or drivability of the
car.
I understand the “Customer Agreement” and agree to the terms outlined above.
_______________________________________________________________________________________________
Signature
Date
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