DRIVEN TO SERVE APPLICATION

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

TRANSPORTATION SITUATION ASSESSMENT

1. Current Transportation Access *

Yes

Do you currently have access to a reliable vehicle for daily needs?

If yes: Year/Make/Model

If yes: Is it reliable?

Yes

What issues exist with your vehicle?

If Other, please explain:

3. What essential needs are difficult due to transportation challenges? *(Check all that apply)

If Other, please explain:

4. Primary Barrier to Owning a Vehicle *

Insufficient income

Credit challenges

High expenses (e.g., medical)

Other

If Other, please explain:

5. Why a Donated Vehicle Matters to You *

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 Assets

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:

UPLOADS

DD214 *

Accepted file types: jpg, gif, png, pdf.

VA Disability Letter - If Application

Accepted file types: jpg, gif, png, pdf.

Paystubs - IF Employed /LES (active duty)

Up to 5 documents

Accepted file types: jpg, gif, png, pdf.

Have you ever been convicted of, or entered a plea of guilty, guilty but mentally ill or nolo contendere to a gross misdemeanor and/or felony? *

Yes

If you answered YES, you are REQUIRED to attached a written explanation and the final court issued disposition document OR a brief written explanation of the discipline imposed by any real estate regulatory agency or commission on an attached sheet. *

Accepted file types: jpg, gif, png, pdf

APPLICANT ACKNOWLEDGEMENTS

(Please check each box to confirm your understanding and agreement.)

ACKNOWLEDGEMENTS *

I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may result in disqualification from the program

I understand that selection is not guaranteed and that all applicants are subject to a vetting process conducted by VETCares per U.S. Bank program wheelchair donation guidelines.

I agree to fully cooperate throughout the vetting and selection process, including providing references, a short biography, photographs, and any additional documentation reasonably requested.

I agree to participate in required virtual meetings or interviews (e.g., Zoom, Microsoft Teams) as part of the review and selection process.

If selected, I agree to comply with all pre- and post-donation program requirements established by VETCares and U.S. Bank’s wheelchair donation guidelines.

I understand that the donated wheelchair is intended to support my personal transportation and stability. I agree that I will not sell, transfer, or otherwise dispose of the vehicle for a period of twenty-four (24) months following the date of donation, except with written permission from VETCares.

TALENT & MEDIA RELEASE *

By submitting this application, I grant VETCares and U.S. Bank permission to use my name, likeness, image, voice, photographs, and story for program-related communications, including websites, social media, reports, and promotional materials, without compensation. I understand this may include written, photographic, and video content created during the application, vetting, and donation process.

Tax & Legal Disclaimer *

I understand that I am responsible for any personal tax or legal obligations associated with receiving a donated wheelchair.

Background Check

I understand and consent to VETCares conducting a local, state, and federal background check as part of the vetting and selection process. I acknowledge that eligibility may be affected by the results of these checks.

Signature (Use your mouse to sign) *

Clear

Date *