A&E AUTOS 4 THE NEEDY, INC
A & E AUTOS 4 THE NEEDY, INC. NONPROFIT PROGRAM

A & E Autos 4 The Needy, Inc. is an approved 501 (C) (3) nonprofit corporation whose mission is to help individuals in need obtain transportation that will improve their quality of life which includes their ability to locate employment, hold employment and thrive independently

Email address
I. Recipient Information
Name
First and Last Name
Your answer
Guardian Name (If appropriate)
Your answer
Primary Telephone #:
Your answer
Alternate Telephone #:
Your answer
Social Security #:
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Driver's License Number
Your answer
State
Your answer
Expiration Date
MM
/
DD
/
YYYY
II. Financial Information
Total Salary / Wages / Unemployment:
If none, please type $0.00
Your answer
Total Social Security Income:
If none, please type $0.00
Your answer
Pension/Social Security Income:
If none, please type $0.00
Your answer
Social Security Disability Income:
If none, please type $0.00
Your answer
Other (List sources):
If no other sources, type N/A
Your answer
TOTAL ANNUAL GROSS INCOME:
Your answer
Household Size (Number of persons who contribute to or are dependent on recipient’s household income):
Your answer
Do you file federal taxes? If yes, provide a copy of your most recent return.
III. General Information
Car Insurance: Have you ever been insured?
If so, what company (provide name, address, phone number)? If not, type N/A
Your answer
Do you currently have car insurance?
If so what company? If not, type N/A
Your answer
Have you, at any time, lost your driver’s license as the result of a crime, accident, or other reason?
If so, explain. If not, type N/A
Your answer
What is your reason (need) in applying for this program? Please explain.
Your answer
“I promise that the information on this form is correct and complete. If needed, A&E Autos 4 The Needy, Inc. may request and obtain information about my or my family’s income and need to enroll me in this Program. I understand that the Program administrators reserve the right any time and without notice to modify the application form; modify or discontinue any or all of theProgram and the related eligibility criteria; or terminate assistance provided by the Program at any time.”

Please indicate your agreement with these terms by signing below

Signature (Full Name In Capital Letters):
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