REQUEST FOR TRANSPORTATION ASSISTANCE
Customer Name ________________________________ Employer/Job Training _____ _______________
Address____________ _______________ Address ________________________________
City & Zip Code ________________________________ City & Zip Code _________________________
Phone # ________________________ ___ Phone # _______________________________
Social Security# _______________________ ___ ____ Today’s Date ___________________________
Client Signature ________________________________
REQUIRED INFORMATION
Please list all persons living in the home below.
Name
Age Relationship to Applicant Employed
____________________ _____ __Self
______________ __________
____________________ _____ ____________________ __________
____________________ _____ ____________________ __________
____________________ _____ ____________________ __________
You must provide documentation of all income for the last 30 days and complete the
following vehicle information in order to be considered for assistance. This information may
be verified through the Department of Motor Vehicles.
Please check:
Bus Rider
Yes
No
Mileage Reimbursement Yes No
Car Repair
Yes No
Car Insurance
Yes No
License Plate Number
Vehicle Make/Model
Vehicle Identification #
Owner (name on registration)
Insurance Carrier
Policy Number
All Household Income:
Please check all that apply:
Wages
SSI
Unemployment
Child Support
Other ____________________
THIS SECTION MUST BE COMPLETED BY REFERRING WORKER/CASE MANAGER
Case Manager /Referring Worker Dist. #
Case ID
Amount of monthly gross household’s income
Number of hour’s customer works per week.
Is Household 200% below poverty level?
Mail Applications to: Community Resource Division – Partnership Services, 301 Billingsley Rd. Charlotte, NC 28211
Contact Number: 704/336-4809 Fax Number: 704/336-8046
click to sign
signature
click to edit
![]()
