Financial Needs Analysis

This Needs Analysis is solely used to determine applicant’s ability to pay in-full, partially, or at all for any automobile that is part of the Muslim Mobility program. The information submitted by the applicant will only be used to assess this financial capability and to determine the actual needs of the applicant and for applicant’s need for a vehicle. All information is kept in strict confidence and is not shared, sold or circulated for any reason whatsoever.

Primary Applicant

Title

First Name and MI

Last Name

Date of Birth

Marital Status

Home Address

Postal Code

Home Phone

Work Phone

Cell Phone

Email Address

Social Security Number

Children/Dependants

1. Given Name/Date of Birth/Dependant till age/Gender

2. Given Name/Date of Birth/Dependant till age/Gender

3. Given Name/Date of Birth/Dependant till age/Gender

4. Given Name/Date of Birth/Dependant till age/Gender

5. Given Name/Date of Birth/Dependant till age/Gender

Employment Details

Employment

Occupation

Commencement Date

Work Address

Income Details

Annual Gross Salary

Bonuses/Tips/Commissions

Alimony

Retired Income

Rental Income

Dividend Income

Social Security Benefits

Welfare Assistance

EBT / General Relief

Other Income

Do you forsee any substantial change to your income in the next tear?

Yes No

If Yes: Please etail In the notes below:

Do you expect to be a beneficiary of an estate or receive any other injection of money/income/wealth in the next year?

Yes No

If Yes: Please detail In the notes below:

The Information submitted and any statements made concerning my income are true and correct to the best of my knowledge

Household Expenditures

Utilities Monthly Expenses

Gas

Water

Electricity

Telephone/Mobile

Television

Auto Monthly Expenses

Fuel

Repairs and Maintenance

Food

Groceries

Dining Out

Insurance Monthly Expenses

Life

Disability

Home

Health

Car

Health Care Monthly Expenses

Doctor/Dental/Optical

Pharmaceutical

Hospital/Cover

Personal Care Monthly Expenses

Clothing

Dry Cleaning

Hairdressing and Cosmetics

Entertainment Monthly Expenses

Memberships and sports

Holiday

Cd's, Video's, Movies

Other Monthly Expenses

Total Expenditure

Annual Surplus/Shortfall

Total Expenditure

Extraordinary Expenditure:

Do you have any significant existing or planned expenses (e.g. new car, holiday, home renovation, etc)

Yes No

If yes, please detail in notes below:

Primary Applicant

Existing

Amount

From

Premium $

Balance Due $

Life Insurance:

Yes No

Health Insurance:

Yes No

Home Insurance:

Yes No

Renter’s Insurance:

Yes No

Business Insurance:

Yes No

Loans:

Yes No

Loans:

Yes No

Mortgage:

Yes No

Credit Card 1:

Yes No

Credit Card 2:

Yes No

Other:

Yes No

Business Expenses

Accounting Fees

Rent

Lease Costs

Salaries to employees

Other employee costs

Utilities

Other

Total

Your Muslim Mobility Case Manager will contact you once your Needs Analysis has been completed and a determination of eligibility is made. You may be eligible for a full donation of a vehicle; or you might be required to pay a down payment on a vehicle and Muslim Mobility will cover the balance; or you may receive down payment assistance and then be required to make monthly payments to pay off a vehicle purchased through Muslim Mobility; or you may be denied any assistance based upon the information obtained and verified by Muslim Mobility.

To determine the most appropriate course of action, your Case Manager may need to ask you some questions about your goals and needs and the exact timeframe in which you want to achieve or fulfill them. By answering the following questions, you will help us decide how Muslim Mobility can best help you:

1. Why do you think it is important for you to have a vehicle? How will it benefit you and your family?

2. If you get a vehicle will you be able to pay for registration and insurance?

3. If you get a vehicle, can you maintain insurance on the vehicle and keep up maintenance on the vehicle?

4. If you get a vehicle, can you maintain insurance on the vehicle and keep up maintenance on the vehicle?

I acknowledge that the information contained in this Financial Needs Analysis is true and correct to the best of my/our knowledge. I am not aware of any other information that I have failed to disclose;

I give my permission for this information to be used in determining my eligibility for a vehicle or for assistance from and through Muslim Mobility.

I permit this information to be passed in confidence to Muslim Mobility and to any of its employees and/or authorized representatives, to my assigned Case Manager, and to any of Muslim Mobility’s related companies.

I have received made a copy of the information I have provided and will keep it on file for personal use;

I authorize Muslim Mobility, any of its employees and/or authorized representatives, and my assigned Case Manager, to verify my information. I also give permission for Muslim Mobility to use my Social Security Number to verify my financial and other information as submitted herein.

Applicant’s Electronic Signature:

Date

Financial Needs Analysis

Primary Applicant

Children/Dependants

Employment Details

Income Details

Household Expenditures

Utilities Monthly Expenses

Auto Monthly Expenses

Food

Insurance Monthly Expenses

Health Care Monthly Expenses

Personal Care Monthly Expenses

Entertainment Monthly Expenses

Other Monthly Expenses

Primary Applicant

Existing

Amount

From

Premium $

Balance Due $

Life Insurance:

Health Insurance:

Home Insurance:

Renter’s Insurance:

Business Insurance:

Loans:

Loans:

Mortgage:

Credit Card 1:

Credit Card 2:

Other:

Business Expenses

Business Expenses

Accounting Fees

Rent

Lease Costs

Salaries to employees

Other employee costs

Utilities

Other

Other

Total

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