CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
Consumer Assistance Program Application
Receive up to $1,500 to Retire Your Vehicle
Para obtener una solicitud en español, llámenos al 800.952.5210.
Please fill out the application completely. Incomplete applications cannot be processed and may be returned.
CAP/APP (07/12)
Program Option (Choose only one)
Vehicle Retirement Income eligible vehicle owners may receive $1,500 to retire their vehicle. All others
may receive $1,000.
Repair Assistance Income eligible vehicle owners may receive up to $500 in emissions-related repairs if
their vehicle fails a biennial Smog Check inspection.
For a complete list of eligibility requirements, please visit www.smogcheck.ca.gov.
Registered Owner Information
LAST NAME
FIRST NAME
M.I.
DRIVER LICENSE OR I.D. #
MAILING ADDRESS
APT.
CITY
STATE
ZIP
Joint Registered Owner Information (if applicable)
LAST NAME
FIRST NAME
M.I.
DRIVER LICENSE OR I.D. #
Vehicle Information
VEHICLE YEAR
MAKE
MODEL
VEHICLE IDENTIFICATION # (VIN)
Income Verification
NUMBER OF PEOPLE (INCLUDE YOURSELF) LIVING IN THE HOUSEHOLD IS: __________
GROSS HOUSEHOLD INCOME IS: $_______________ MONTHLY YEARLY
Signature(s) Required
I acknowledge that the information provided on this application will be used to assess and verify my eligibility for assistance, and upon
request, I may be required to provide documentation to the Bureau of Automotive Repair verifying household income. My signature gives
consent for this information to be shared with other government agencies. I declare, under penalty of perjury under the laws of the State of
California, that to the best of my knowledge, the information on this application is true and correct. I understand that submitting false
information may result in a criminal conviction in addition to civil penalties, and that I will not be eligible to receive future assistance in the
Consumer Assistance Program (CAP). I further understand and agree that if my vehicle does not meet all program eligibility requirements, it
will not be allowed into the CAP.
Registered Owner
Print Name: ________________________________ Signature: ________________________________ Date: __________
Joint Registered Owner
Print Name: ________________________________ Signature: ________________________________ Date: __________
MAIL YOUR COMPLETED APPLICATION TO:
Bureau of Automotive Repair, Consumer Assistance Program, 10949 N. Mather Blvd., Rancho Cordova, CA 95670
Vehicle retirement and repair assistance can only be performed at State approved facilities. CAP will not reimburse consumers
for work performed prior to the approval of an application. Financial assistance is based on the availability of funds.
Questions? Please call 866.272.9642 or visit www.smogcheck.ca.gov.
Pursuant to Section 1798.17 of the Civil Code (Information Practices Act), the Director of the Department of Consumer Affairs is responsible
for maintaining the information in this application. Information may be transferred to other governmental agencies if required. Individuals have
the right to review the records maintained on them by the agency, unless the records are exempted by Section 1798.40 of the Civil Code.
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