ALL-TERRIAN WHEELCHAIR APPLICATION

Payment-free Wheelchair Donation

In Partnership with U.S. Bank

APPLICATION INFORMATION

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Cellphone *

Other Phone

How did you hear about this program? *

Other - How did you hear about this program?

Email *

DISCLOSURES

Are you related to or do you have business ties to any VAREP staff, members of their immediate families, VAREP Board members, members of their immediate families, and such individual’s business associates? *

Yes

If Yes, Name

Relationship

ALL-TERRAIN WHEELCHAIR NEEDS ASSESSMENT

Do you currently have a wheelchair or mobility device? *

Yes

If yes: What type? (Wheelchair or mobility device)

Other (Wheelchair or mobility device)

Is your current mobility device adequate for outdoor, rough terrain use? *

Yes

What difficulties do you experience with your current device? Check all that apply

How often do you expect to use an ATW? *

Daily

Weekly

Monthly

Seasonally / Occasionally

Check all that apply

What are the primary purposes for using an ATW? *Check all that apply

Please describe any specific physical needs or preferences related to seating, controls, supports, or accessories:

MILITARY/ HERO DETAILS

Branch of Service/Hero Affiliation *

Military Status *

Pay Grade

MOS/Rate/Job Title

Command

Years of service *

Dates of deployments/When will you deploy/ Location of deployments

FAMILY

Family Status *

Married

Single

Divorced

Widowed

Household size *

Family Members

Member 1
Member 2

Add Name, Age and Relation to Applicant

EMPLOYMENT

Are you currently employed: *

Yes

Employer name (If yes)

Supervisor Name – If employed

Supervisor Phone – If employed

May We Contact Your Supervisor for Reference Check?

Yes

FINANCIAL STATEMENT

Income – Monthly Gross Amount

Primary Employment (Gross)
Spouse/Co-Borrower Employment (Gross)
Self-Employment / Business Income
Retirement / Pension
Social Security
Child Support / Alimony
Other Regular Income
VA Service-Connected VA Disability (if applicable)

If other was selected, please explain

Total Monthly Household Income (all sources)

Expenses- Monthly Amount

Current Rent or Mortgage
Property Taxes (if separate)
Homeowners/Renters Insurance
HOA Dues
Utilities (electric, gas, water, trash)
Auto Loans/Leases
Credit Cards (minimum payments)
Student Loans
Personal Loans
Childcare
Child Support/Alimony Paid
Food & Household Supplies
Transportation & Fuel
Medical/Insurance Out-of-Pocket
Other Monthly Obligations

If other was selected, please explain

Total Monthly Expenses

LIQUID ASSESTS

Please list current balances. Enter $0 if not applicable.

Asset Type- Current Balance ($)

Checking Account(s)
Savings Account(s)
Money Market Account(s)
Cash on Hand

Total Liquid Assets:

REFERENCES- LIST 2 REFERENCES

Reference 1 Name *

First Name
Last Name
Phone Number (Reference 1 )

Reference 2 Name *

First Name
Last Name
Phone Number (Reference 2)

UPLOADS

Government Issued ID *