Application for Vehicle Waiting List

1. ABOUT THE APPLICANT

First Name *

Last Name *

Today's Date *

CA Driver's License Number *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Email

Confirm Email

Cell Phone Number *

Secondary Cell or Home Phone Number

Are you working now? *

Other:

Have you applied for any assistance from MCC before? *

Yes
No

What field of work are you working in now or were most recently employed in? *

If working, company name? *

Salary: *

Job Position: *

If working, how far is your commute and how do you currently get to work? *

Did you arrive to the U.S. under a federal refugee resettlement program in the past two years? *

Yes
No

If yes, when did you arrive in the U.S., via which agency, and what is your country of origin:

2. ABOUT YOUR HOUSEHOLD

Your marital status: *

If married, is your spouse currently employed?

Yes
No

If yes, where does your spouse work (company name & address):

Job title:

Hourly wage:

Does your spouse have a vehicle?

Yes
No

If yes, what is the year, make, model of your spouse’s vehicle?

Number of dependents in the household: *

Enter the name, date of birth, and relationship of each person living in your household: *

3. ABOUT YOUR HOUSEHOLD INCOME AND EXPENSES

Monthly Gross Income:

Income From Work (you and your spouse) *

Social Security Income *

Child Support *

Aid/Welfare, Food stamp *

Family Assistance *

Other Sources: *

Specify other:

Total: *

Monthly Expenses:

Rent/mortgage *

Utilities/Phone *

Food *

Car payment, Insurance *

Medical expenses *

Other (i.e. debt and loan payments) *

Specify other:

Total: *

Current Household Assets:

Checking *

Savings *

Gold or Silver (cash value) *

Vehicle(s) (fair market value) *

IRA, Pension, Stock, mutual funds *

Other (cash value) *

Total: *

4. VEHICLE IMPACT STATEMENT

How long have you been a licensed driver in the U.S.? *

When did you most recently own a vehicle? *

What were the circumstances around becoming car-less? *

Is your intent in asking for a vehicle so that you may use this vehicle for ride-sharing (Uber/Lyft)? *

Yes
No

How would receiving a vehicle donation positively impact your household? (BE DETAILED; do not just state a vehicle would help your household.) *

Have you ever received a car via any other donation program? *

Yes
No

Are there currently any other vehicle(s) in your household? *

Yes
No

If yes, what is/are the year, make, and model and who owns each?

Which type of vehicle would have the most impact on your household? *

Before you may pick up a vehicle from MCC, obtaining and showing proof of insurance is mandatory. How will you do so? *

5. REFERENCES

Please list at least two names of references whom you are familiar with and who can confirm or verify the information you provided in this application. References cannot be immediate relatives or people you live with.

Name, phone, relationship to you: *

Please check each box on this checklist to confirm your understanding and that you are submitting a true and complete application to the MCC: *

Yes, I have included a CLEAR COPY of my California Driver’s License in the Document Upload section below. Please do not complete form if you are not a licensed California driver.
Yes, I understand that simply completing this form does not mean automatic approval of the application. I maybe asked to provide supporting documents to substantiate the validity of information I have provided.
Yes, I understand that MCC’s Vehicle Donation Program is exclusively for residents living with a valid address in the San Francisco Bay Area. MCC facilitates donated vehicles on a need-basis and as vehicle donors in the community offer vehicles for donation through MCC. MCC facilitates the donation and it does not control the duration a person waits on the waiting list.
Yes, I understand that I will be responsible for insuring the vehicle before I may pick the vehicle up from MCC. If I cannot afford to insure the donated vehicle, once or if MCC contacts me with a waiting vehicle, I may complete a Zakat application (downloadable at mcceastbay.org/zakat for the MCC Zakat Committee to consider payment on a three-month policy or a six-month policy on a donated vehicle).

6. STATEMENT: Please read the following statement and sign below.

I testify in front of God that the information provided in this application is true and accurate to the best of my knowledge. I understand that if any information given turns out to be untrue, this application will automatically be denied and that MCC may permanently bar me and my spouse from applying for any future assistance as well as sharing my information with other Bay Area masjids that give out Zakat and Sadaqa assistance.

Your Name: *

Date: *

7. DOCUMENT UPLOAD

Copy of California Driver's License *

Click or drag files to this area to upload. You can upload up to 4 files.