Benevolence Car Giveaway Application

FILL OUT AND SUBMIT YOUR BENEVOLENCE APPLICATION BELOW

PERSONAL INFORMATION



MONTHLY INCOME/EMPLOYMENT INFORMATION


Wages

Unemployment

Workers Comp

Pension

Social Security

TANF

Disability

Other

Statement of Need
I certify that:
  • I am a resident of the City of the Ben Clymer’s shop giving the car away.
  • I am willing to share my story with the media.
  • I am willing to provide any needed verifications to validate my need for this car.
  • I have and will provide proof of a valid, current California driver’s license.
  • I have a clean DMV record. am able to be insured.
  • I will sign release forms for media and liability.
  • The information in this application is true to the best of my knowledge.