Smog Check Consumer Assistance Program Application (Page 4 of 4) in pdf

California Department of Consumer Affairs

Bureau of Automotive Repair

SMOG CHECK

CONSUMER ASSISTANCE PROGRAM APPLICATION

ease fill out the application completely. Incomplete applications cannot be processed.

SECTION 1 — PROGRAM SELECTION

Please check one:

REPAIR ASSISTANCE: INCOME ELIGIBLE APPLICANT — If this box is checked, complete Sections 2-5, sign and date the

application. Mail the application with the required documents to the address at the bottom of the page.

REPAIR ASSISTANCE: TEST-ONLY ELIGIBLE APPLICANT — (Note: Test-Only Eligible applicants should apply as Income Eligible

applicants, if they qualify.) If this box is checked, complete Sections 2-4, sign and date the application. Mail the application with the required

documents to the address at the bottom of the page.

SECTION 2 — REGISTERED VEHICLE OWNER INFORMATION

Last Name, Registered Owner

First Name

Middle Init.

Driver’s License or I.D. Number

Street Address

Apt.

City

State

ZIP

Daytime Phone Number

(

)

Last Name, Joint Registered Owner (if applicable)

First Name

Middle Init.

Driver’s License or I.D. Number

SECTION 3 — VEHICLE INFORMATION

Vehicle Year

Make

Model

Vehicle Identification Number (VIN)

California License Plate Number

SECTION 4 — VEHICLE REPAIR INFORMATION (for crediting consumer co-pay only)

I have spent $___________ on emissions-related repairs at______________________________________________________ in an effort to pass my current

Smog Check (attach invoices).

(Name of Smog Check Station)

SECTION 5 — INCOME INFORMATION (for Income Eligible applicants only)

Head of Household? (Please check one)

Number of people living

STEP 2 — Determine whether you are eligible.

in your household

Yes

(include yourself)

STEP 1 — Add the Total Gross Income for all

(A) Total Gross Income (from STEP 1)

0.00

household members, including yourself.

Wages

Welfare/Unemployment Payments

(B) Maximum Household Income

Social Security Payments

from “Income Eligibility Table” on page 2)

CalWORKs Payments

If the amount on Line A exceeds the amount on Line B, you are not eligible

for repair assistance. If the amount on Line A is less than or equal to the

TANF Payments

amount on Line B, please date and sign the application. Be sure to include

Other Income

with your application a copy of one of the documents (listed on page 2) that

0.00

verify your income eligibility.

Total Gross Income

Annual

Monthly

I acknowledge that the information provided on this application will be used to assess and verify my eligibility for assistance. My

signature gives consent for this information to be shared with other government agencies. I declare, under penalty of perjury under

the laws of the State of California, that to the best of my knowledge, the information on this application is true and correct. I

understand that submitting false information may result in a criminal conviction or in a civil penalty of not less than $150 and not

more than $1,000, and that I will not be eligible to receive future assistance. I further understand and agree that if my vehicle does

not meet all program requirements, it will not be permitted into the Consumer Assistance Program.

Registered Owner’s Signature: _______________________________________________________ Date: __________________________

Joint Owner’s Signature: ___________________________________________________________ Date: __________________________

(If Applicable)

Bureau of Automotive Repair

Mail your application

Consumer Assistance Program

and required documents to:

10240 Systems Parkway, Sacramento, CA 95827

CAP/APP (03/03)

Page 4 of 4

OSP 03 66520

Smog Check Consumer Assistance Program Application Page 4

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