UBP Open Shop Compensated Usage Form
The open shop compensated usage program allows individuals in need to receive free used parts and compensated shop time in order to maintain their bicycle. Applicants are allowed to maintain one bicycle through the program. If the bicycle is stolen, missing, or damaged beyond repair there may be a waiting period before a new bicycle can be worked on. The program provides essential parts required for safe operation of the bicycle. Volunteers and staff will choose these parts from UBP’s selection of used parts. UBP will ask participants for a donation of any amount that is meaningful to the applicant.
Have you received a Free Bike from us as part of the Free Bike Program?
Prefer not to answer
American Indian/Native American
Are you homeless or living in transitional housing?
Shelter or transitional housing (Examples are YMCA/YWCA, Sojourners Place, Sunday Breakfast Mission, etc)
Sources Of Income
Please check any that apply
AFDC/TANF (Aid to Families with Dependent Children, Temporary Assistance for Needy Families)
GA (General Assistance)
SS (Social Security)
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
Do you participate in any of the following programs?
Check any that apply
Please Estimate Your Annual Household Income
Household Size/Household Annual Income
To be eligible your annual household income must be lower than the listed amount for household size.
1 - $21,257
2 - $28,694
3 - $36,131
4 - $43,568
5 - $51,005
6 - $58,442
7 - $65,879
8 - $73,316
Do you certify that your annual gross income is at or below the income listed on this form for households with the same number of people as your household, OR that your household participates in the programs that have been checked on this form?
What forms of transportation do you currently use?
Check any that apply
Own a car
Rides from family/friends
Do you have children that you would like to be able to participate with you in the Compensated Usage program?
You must accompany and supervise your children the entire time they are in the shop.
Information about your bicycle - Brand/Make
The compensated usage program is for maintaining one bicycle per applicant.
Serial numbers are usually located under your bottom bracket and are a combination of numbers that sometimes includes letters. Please ask a volunteer for help if you cannot find your serial number.
Type of bike
26 x decimal
26 x 1 3/8
Condition of the bicycle
Missing some parts but still eligible
Damaged beyond repair/reasonable cost
Would you like to sign-up for our E-mail list to learn about events & announcements??
If yes, put your email address here:
Are you interested in volunteering?
Yes (Volunteer orientation is on the first Monday of each month at the shop)
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