Vehicle Repair and Replacement Assistance Application
Weber-Morgan Health Department
477 23
rd
Street Ogden, UT 84401
801-399-7140
SECTION 1: APPLICANT INFORMATION – PLEASE PRINT
Vehicle Owner Name(s): ________________________________________________________________
Street Address: _______________________________________________________________________
City: ______________________ State: UT Zip Code: _______________________
Mailing Address (If different): ___________________________________________________________
Phone Number: _____________________________ Email: ________________________________
SECTION 2: VEHICLE INFORMATION – PLEASE PRINT
Vehicle Make: _______________________ Model: _____________________ Year: ________
Vehicle Identification Number (VIN): _________________________________
License Plate: __________________ Odometer: _________________________________
SECTION 3: INCOME ELIGIBILITY & ID VERIFICATION
Total number of household members: Adults _______ Children _________
- Proof of income will be verified using your most recent Federal Tax Form 1040. This
document must be brought to your appointment.
- ID check required
SECTION 4: AFFIDAVIT AND SIGNATURE – PLEASE SIGN AND DATE
I certify that the information provided in this application is complete, accurate, and true. I understand
that falsification of this information and/or attachments may result in termination from, or denial of the
application for the Vehicle Repair and Replacement Assistance Program. I acknowledge that all
information given is subject to verification.
Signature: _________________________________________________ Date: __________________
SECTION 5: OFFICE USE ONLY
Approved / Denied Repair / Replacement Date: __________________
Assistance Percentage and Amount: ____________________ Applicant ID: _________________
