Fillable Anoka County Transportation Solutions Program

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Anoka County Transportation Solutions Program

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Anoka County
Transportation Solutions Program
Partnership between Anoka County and ACCAP
1201 89
th
Ave NE
Suite 230
Blaine, MN 55434
Phone: (763) 324-2318
Fax: (763) 324-2294
Please keep this page for your records
CAR REPAIR, INSURANCE & LICENSING ASSISTANCE GUIDELINES:
• MUST BE A RESIDENT OF ANOKA COUNTY MN
• Must be low income (at or below 200% Federal Poverty Guideline)
• Verified employment of 20 hours a week unless one of the following applies: disabled, senior (55+) or be
enrolled in an Anoka County Employment and Training Program and be in compliance and meeting
participation hours requirement for at least 30 days.
• Must have a valid Minnesota driver’s license with current address
• Vehicle must be registered in applicant’s name.
• Must have proof of insurance (if applying for repairs only)
• Vehicle repairs must be cost effective (not to exceed 75 % of value of the vehicle)
• A maximum $700 transportation grant for safety and essential operation car repairs only, insurance (up to 2
months on existing policy or on a down payment for a new policy) or vehicle registration.
• Program eligibility – All benefits for transportation needs are limited to a one-time assistance for the
duration of the program
• All grants must be preapproved. No reimbursements.
***Any exceptions to the above criteria would need pre-approval by the program manager.
****Grants are dependent on funding available.
VERIFICATION CHECKLIST:
Submit the application via email to irina.astashinsky@co.anoka.mn.us or fax 763-324-2294 or mail to
CareerForce at 1201 89th Ave NE, Suite 235, Blaine, MN 55434
Fill out and sign ALL
pages of application.
Copy of driver’s license (showing current address) and/or the yellow DMV receipt
Copy of Title of Vehicle or proof of ownership – vehicle must be registered in your name
Copy of insurance card
Copy of your insurance bill (if applying for help with car insurance) or three quotes from local insurance
agencies (if applying for help to start a new policy). Please call transportation coordinator if assistance
is needed finding a local insurance provider.
Copy of tabs bill (or print out from DMV) if applying for assistance with tabs/title transfer
Copy of Pay Stubs for the last 30 days (if employed) or proof of other income. For self-employment:
most recent year tax document or recent business record showing income & expenses.
Onc
e you submit your application, you will have 30 DAYS to supply all required documents. If after 30
days, you have not supplied the required documents your request for service will be denied based on
insufficient information.
LIST OF REPAIRS WE MAY BE ABLE TO HELP WITH:
Tires
Exhaust(case by case basis)
Suspension (shocks, struts, tie rods, ball joints, etc.)
Alternator
Axels (case by case basis)
Brakes (shoes, pads, drums, rotors)
Battery
Windshields or other glass
Minor oil leaks (valve cover gaskets, oil pan, etc.)
Belts
Wheel bearings
Power steering hoses (case by case basis)
Water pump
CV boots and joints
We are NOT able to assist with non-running vehicles, transmissions, engines and other major repairs.
Anoka County Transportation Solutions Program
Partnership between Anoka County and ACCAP
Name (Print)
Maxis Case:
Social Security #
Cell Phone #
Other contact:
List the people who live in your home:
Name
Date of Birth
Relationship
1.
SELF
2.
3.
4.
5.
6.
1) Are you currently receiving Public assistance through MFIP/DWP Yes No
If yes, are you currently in sanction? Yes No
2) Do you have a valid MN driver's license? Yes No
3) Transportation Assistance needed? Car Repair Insurance Vehicle Registration/Tabs
Is your car drivable Yes No
4) What income do you have?
Present
Employer
Date
Started
Phone:
How many hours per week do you work?
Hourly Wage $
Spouse (significant other)
Present Employer
Date
Started
Phone:
How many hours per week do you work?
Hourly Wage $
Other Income: MFIP/DWP $______Food Support $______ UI/WC $______Child Support $______ SS $_________
SSI/RSDI $_____ (who receives___________) Retirement $______Veteran Benefits $______Other $_____________
5) Monthly expenses: Housing (Rent/Mortgage) $_______ Utilities (Gas/electric/water) $_______ Phone $__________
6) Are you looking for work? Yes No Number of hours per week: _______________
Is your spouse looking for work? Yes No Number of hours per week: _______________
7) Does anyone have any bank accounts? Yes No If yes, amount in bank accounts $_______________
8) Cars in the household:
Year
Make
Model
License Plate
Mileage
For Car Repair, describe vehicle problem: _____________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
My signature acknowledges that the information provided is correct, true and complete.
Applicant's Signature:
Date:
click to sign
signature
click to edit
ACCAP (Transportation Coordinator), 1201 89
th
Ave., Suite 230, Blaine MN 55434 Phone 763-324-2318 Fax 763-324-2294
AUTHORIZATION FOR RELEASE AND EXCHANGE OF INFORMATION
and Permission to Verify Application
I ___________________________________________, permit ACCAP (Anoka County Community Action
Program) to share and verify information about me to determine what benefits I may be eligible for. By
signing this Authorization, I agree that ACCAP may share and receive information from the individuals or
organizations that I authorize, which may include ongoing communication.
ACCAP is authorized to share with and receive information from:
• Anoka County Economic Assistance Department
• Anoka County Job Training Center
• Victory Auto Service & Glass
• My employer ______________________________________
• Anoka County License Bureau ____________________________
• Car insurance company __________________________________
• Garage____________________________________________
• Other: (Must specify)
Data that may be shared includes all information necessary to determine need and eligibility for programs
administered by ACCAP and may include, but is not limited to:
• What help ACCAP may give me.
• Information about help the ACCAP gives me now.
• The amount the ACCAP may pay them.
This data is private. The ACCAP may only give this information with my written permission, unless state or federal law
allows them to release data about me without my permission. I understand I may refuse to release this data. If I refuse,
the ACCAP may be unable to give me the assistance requested. The ACCAP will use the information from this
authorization to verify that the information I provided on the application is correct, true and complete.
I hereby authorize ACCAP to release and exchange information pertaining to my applications and eligibility for
programs/services they administer for the purpose of evaluating my need for assistance. This Authorization is valid for
one year from the date I sign it, unless I specifically revoke the Authorization in writing.
Signature of person authorizing release
Date
Warning: Section 1001 of Title 18 of US. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. as
to matters within its jurisdiction.
Anoka County Transportation
Solutions Program
Partnership between Anoka County and ACCAP
click to sign
signature
click to edit
Agency Intake
This form asks for data about you and your family. If you decide not to complete this
form, we may not be able to provide you with all the helpful information and resources
available. If you complete this form, the information will be used to identify resources,
provide information, coordinate services, and create summary data for evaluation and
funding purposes.
Sex ❑ Male ❑ Female ❑ Other
Race ❑ White ❑ Multiracial ❑ Black/African American ❑ Asian ❑ American Indian
❑ Middle Eastern ❑ Hawaiian/Pacific Islander
Employment ❑ Full-Time ❑ Part-Time ❑ Seeking Work ❑ Unemployed ❑ Contract
❑ Temporary ❑ Retired ❑ Other __________________________
Medical Insurance ❑ Yes, Private ❑ No ❑ Yes, State
Housing ❑ Own ❑ Rent ❑ Buying ❑ Homeless ❑ Temporarily Living with Family
Education ❑ Non-Grad ❑ High School/GED ❑ Some College ❑ College Degree
Disability ❑ None ❑ Physical ❑ Mental ❑ Cognitive ❑ Visual ❑ Blind ❑ Speech
❑ Hearing ❑ Deaf ❑ Breathing ❑ Orthopedic ❑ Other
Family Type ❑ Single Person ❑ Single Parent/Female ❑ Single Parent/Male
❑ Adults w/Children ❑ Adults w/o Children
Language ❑ English ❑ Spanish ❑ Hmong ❑ Chinese ❑ Vietnamese ❑ Japanese
❑ Korean ❑ Hattian ❑ Somali ❑ Arabic ❑ Karen ❑ Oromo ❑ Cambodian ❑ Russian
❑ Other _________________
Veterans Status ❑ Veteran ❑ Active Military ❑ No Military Background
Special Circumstance ❑ Domestic Abuse ❑ Pregnant Teen ❑ Non-Parent Caregiver
Non-Cash Benefits
❑ Parenting ❑ English Language Learner ❑ TANF/MFIP/DWP
❑ Food Stamps (SNAP) ❑ WIC ❑ LIHEAP ❑ Housing choice voucher
❑ Public housing ❑ Permanent supportive housing ❑ HUD-VASH
Childcare voucher ❑Affordable Care Act Subsidy ❑ Other ____________
Signature of Applicant Date _____
Anoka County Community Action Program
Inc.
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signature
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Anoka County Transportation Solutions Program

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Completed 29 March 2021

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