Vehicle Repair Assistance FORM – English Required Contact Information SECTION 1: APPLICANT INFORMATION State: UTID SECTION 2: VEHICLE INFORMATION SECTION 3: INCOME ELIGIBILITY Proof of income for each adult household member must be brought to your appointment. Total number of household members Names of Other Adult Household Members SECTION 4: AFFIDAVIT AND SIGNATURE 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. REQUIREMENTS OF VEHICLE OWNER The vehicle owner name listed on the application must be the same name listed on the registration and title of the vehicle. Income can be verified using the most recent year’s: Federal Income Tax 1040 Form (use Adjusted Gross Income); W2; Disability or Social Security documents; or pay stubs for the last two months. REQUIREMENTS OF VEHICLE The vehicle must have failed an emissions inspection within the past 30 days of the application date. The vehicle must currently be registered in Cache County, UT, Franklin County, ID, or be operated within Cache or Franklin Counties. The vehicle must have been registered in the applicant’s name for at least 12 months preceding the application. The vehicle must be model year 1996 and newer, and cannot have any missing or tampered emissions control devices to qualify for repair assistance. Diagnostic and repair charges incurred prior to receiving a valid voucher will be denied. The vehicle must be model year 2003 or older to qualify for replacement assistance. IF ALL REQUIREMENTS ARE MET, THE FOLLOWING REPAIR ASSISTANCE IS AVAILABLE 200% and below poverty level – 100% of qualifying bill up to $1,000 for diagnostic and repair 201-250% of poverty level – 75% of qualifying bill up to $750 for diagnostic and repair 251-300% of poverty level – 50% of qualifying bill up to $500 for diagnostic and repair IF ALL REQUIREMENTS ARE MET, THE FOLLOWING REPLACEMENT ASSISTANCE IS AVAILABLE 200% and below poverty level - $4,000 (Tier 2 Bin 5 through Tier 2 Bin 3) to $5,000 (Tier 2 Bin 2 or cleaner) 201-250% of poverty level - $3,500 (Tier 2 Bin 5 through Tier 2 Bin 3) to $4,500 (Tier 2 Bin 2 or cleaner) 251-300% of poverty level - $3,000 (Tier 2 Bin 5 through Tier 2 Bin 3) to $4,000 (Tier 2 Bin 2 or cleaner) HOW TO SUBMIT AN APPLICATION Mail, hand deliver, or fax application, failed emissions inspection, and proof of vehicle registration to: Bear River Health Department | ATTN: Vehicle Repair Assistance Program | 85 East 1800 North | North Logan | UT | 84341 | 435-752-1570 (fax) Appointments will normally be scheduled within one week of receiving a complete application Income documents will be verified during your appointment. Please do not send them via mail or fax. Click the SEND button only once. It will take just a moment to process your information. You will receive a confirmation email if your submission was successful.