Emergency Auto Repair Assistance

I have read the document outlining information on eligibility, qualifying expense, application process and required documentation to apply.*

I meet the requirements to submit an application

Please note: You cannot save your application and return at a later time to complete the submission. All required fields and documents must be submitted in one sitting. All required fields must be completed, including uploaded documentation, or your application will be not be considered.

Applicant's Name*

First Last

Are you a current client of JFCS?*

Yes
No

If so, who is the staff person you work with regularly?

Please note: If you or a member of your household is currently a JFCS client and in need of financial assistance, reach out to the JFCS staff person you work with regularly.

Date of Birth*

Address*

Street Address City State ZIP Code

Phone*

Email*

Household Members’ Name(s) and Birthdate(s)*

(First name, Last Name, Date of birth)

What is your faith or religion?*

Note: This information is asked from applicants for grant writing purposes and your response does not affect eligibility for assistance.

How did you hear about JFCS?*

What is the cost of your auto repair according to your repair estimate?*

*For application to be considered, estimate total must not exceed $1800 and must be dated within the last 30 days.

If the amount of assistance you are requesting is different than the amount of the repair estimate, please note that here.

Please describe the event that has disrupted your finances.*

Please report all income and expenses for your household. For income/expenses with fluctuating amounts from month to month, please provide your best estimate on an average monthly amount.

MONTHLY INCOME

Please use $0 for blank responses.

Applicant's monthly salary*

Monthly salary from others*

Any Income from Social Security*

How much Social Security, SSI, or SSDI are you receiving each month?

Pension*

Rental/Business Income*

Interest/Dividend Payments*

Unemployment*

SNAP/Food Support*

MFIP/GA*

Child Support*

Spousal Support*

Financial Support from Others*

Other Income*

MONTHLY EXPENSES FOR THE HOUSEHOLD

Please use $0 for blank responses.

Rent/Mortgage*

Rent/Home Insurance*

Electric/Gas*

Phone/TV/Internet*

Food Expenses*

Car Payment*

Car Insurance*

Car Maintenance/Gas*

Bus/Taxi/Shared Ride Service*

Medical Insurance*

Other Health/Medical Expenses*

Household Supplies/Maintenance/Services*

Personal needs/Clothing/Toiletries*

Child Care*

Tuition/Education*

Credit Card Payment*

Pet Care*

Other regular debt or payments*

Required Documentation must be uploaded below.

Files accepted include PDF, JPG, PNG, DOCX

Estimate from auto repair shop*

Accepted file types: pdf, jpg, png, docx, Max. file size: 50 MB.

*For application to be considered, estimate total must not exceed $1800 and must be dated within the last 30 days.

Proof of current auto insurance*

Accepted file types: pdf, jpg, png, docx, Max. file size: 50 MB.

Proof of valid driver’s license*

Accepted file types: pdf, jpg, png, docx, Max. file size: 50 MB.

I certify the information provided is complete and accurate to my knowledge. I understand JFCS considers one application per household at a time and available funding is capped. Therefore, if another member of my household applies, JFCS may disclose the status and/or determination of this application as it relates to applicants’ eligibility and grant limits. I understand there is no guarantee all applications can be approved.*

I agree

Please type your name as an electronic signature of this form*

Date*

I am also interested in discussing:

Mental Health Support
Food Resources
Career Services
Support for Seniors
Programs for children & families

Emergency Auto Repair Assistance Application

Please note: You cannot save your application and return at a later time to complete the submission. All required fields and documents must be submitted in one sitting. All required fields must be completed, including uploaded documentation, or your application will be not be considered.

Please report all income and expenses for your household. For income/expenses with fluctuating amounts from month to month, please provide your best estimate on an average monthly amount.

MONTHLY INCOME

MONTHLY EXPENSES FOR THE HOUSEHOLD

Required Documentation must be uploaded below.