WTW Auto Repair Request 4-21

COUNTY OF NEVADA
CalWORKs / Welfare to Work Program
Participant Request for Car Repairs

PARTICIPANT INFORMATION
Participant Name*
Social Security Number*
WTW Social Worker
Repairs that are needed (attach estimates)
Repairs that are needed (Description)
Repairs that are needed (attach estimates)

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Please explain why repairing your car is the most effective means of helping you and your family move toward self sufficiency.
Have you selected a licensed mechanic?

YesNo
If yes, please specify their Full business name, Address and Phone Number, below:
Full Business Name:
Address
Phone Number
Please enter a valid phone number.
Name of employer, school or training provider
Address
Round trip miles you will need to travel each day (include the miles you travel to the training or work site. as well as the miles you will travel to reach your child care provider).
PLEASE BE PREPARED TO DISCUSS THE FOLLOWING WITH YOUR WTW SOCIAL WORKER:
- Have you considered other options?
- Make, model, year of the vehicle to be repaired
- Odometer reading and condition of the car
- Registered ownership
- Current driver's license
- Insurance, safety, liens and related legal issues
- Written estimates from a licensed mechanic
I declare under penalty of perjury. that the above information is complete. true and correct.
Submit verification documents here

Cancelof
Signature*
Date*

MonthDayYear
mm/dd/yyyy
WTW SOCIAL WORKER RECOMMENDATION
If applicable, please attach a list of other car repairs funded by CalWORKs for this participant

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SW Certifying Signature:
MANAGER'S AUTHORIZATION

ApprovedDenied
Reason for denial:
Manager's Signature:
Date

MonthDayYear
mm/dd/yyyy
Should be Empty:

COUNTY OF NEVADACalWORKs / Welfare to Work ProgramParticipant Request for Car Repairs

Repairs that are needed (attach estimates)

COUNTY OF NEVADA
CalWORKs / Welfare to Work Program
Participant Request for Car Repairs