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
Guardian Name (If appropriate)
Primary Telephone #: *
Alternate Telephone #:
Social Security #: *
Date of Birth *
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/
DD
/
YYYY
Gender *
Driver's License Number *
State *
Expiration Date *
MM
/
DD
/
YYYY
Please upload a copy of your Driver's License here
II. Financial Information
Total Salary / Wages / Unemployment: *
If none, please type $0.00
Total Social Security Income: *
If none, please type $0.00
Pension/Social Security Income: *
If none, please type $0.00
Social Security Disability Income: *
If none, please type $0.00
Other (List sources): *
If no other sources, type N/A
TOTAL ANNUAL GROSS INCOME: *
Household Size (Number of persons who contribute to or are dependent on recipient’s household income): *
Do you file federal taxes? If yes, provide a copy of your most recent return. *
Upload your most recent tax return here, if applicable.
Car Insurance: Have you ever been insured? *
If so, what company (provide name, address, phone number)? If not, type N/A *
Do you currently have car insurance? *
If so what company? If not, type N/A *
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 *
What is your reason (need) in applying for this program? Please explain. *
“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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