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TEXAS DRIVER RESPONSIBILITY PROGRAM lndigency/ Incentive Application for Reduction of Surcharges

You are applying to the lndigency/lncentive Programs and the Department or its designee will determine the program you qualify for by the supporting documentation you submit.

Print Full Name:

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DL/ID/DPS Assigned N:m,er:

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Date of Birth (MM/DD/YYYY):

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All questions must be answered in full to be reviewed and considered for acceptance into the program.

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Fo• Offi~Un Oo~o

*Other Household Income: This includes all other household income not included previously.

Name

Monthly Amount

Source

Relationship

*************************************************************************************

The following information will be used to determine your eligibility. NOTE: You will be required to send supporting documentation with this application. If your application is incomplete, it will be returned to you with a request for the additional information required.

Y~Household:

Iff

I live alone and support myself.

D I have dependents and support

others

_

Please list their name(s) and relationship to you. You are required to provide proof of dependents.

D I am a dependent and am supported by someone else.

Please list their name(s} and relationship to you. You are required to list their income under "Other Household Income."

D

I reside in housing, either partially or completely funded by government, or private assistance.

D

I am incarcerated -

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,

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,

,

,

,

,

,

---------

Please list TDCJ or County Jail Inmate Number

Employment & Income Information:

(Provide gross income, before taxes, and unemployment benefits, if applicable}

1r am

rv"am not

employed

or

r

self employed

If unemployed, when did you file for unemployment?----,.------ Please explain reason, if you did not file for unemployment: tJ.:.f eAN!plfLJ

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*All Income:$

per week

OR

$

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per month

*Include all of your income received within the past 12 months from all employment, business, or income from rent payments, Social Security, Veteran benefits, interest, dividends, retirement, annuity payments, or any other sources· Income from others household members will be included under "Other Household Income'. (If you entered zero income above, you are required to provide supporting documentation regarding your living status.}

Cash Assets:

I have the following accounts (please list balances):

Checking: $30

Savings: $_Q_ Money Market: $

Pre-Paid/Debit:$

Supporting Documentation:

You will be required to submit supporting documentation to verify your eligibility for the lndigency/lncentive Programs. Check those you are submitting with your application.

Do not send original documents. They will not be returned.

D

A copy of SSI benefits statement.

D

A copy of the most recent Medicaid benefits statement.

IB" A copy of your two (2) most recent and complete bank statements.

D

D

D

D

D

D

D

~

(General overview statements will not be accepted.)

Your most recent 1040 and related 1099.

(Please note that additional evidence of income may be requested to determine most current income status)

Evidence of dependents, if not listed on the previous documents.

A copy of your two (2) most recent pay statements.

A copy of the two (2) most recent pay statements from Other Household income listed above.

A copy of your Unemployment approval or denial letter.

A copy of your Veteran Benefits statement.

Evidence of housing assistance which may include a Government Housing contract.

Other applicable documentation.

COMPLETE NOTARIZATION ON THE BACK SIDE BEFORE SUBMITTING

INC-A (V2.0 07/13)

Page 1 of 2

II

I

TEXAS DRIVER RESPONSIBILITY PROGRAM lndigency/ Incentive Application for Reduction of Surcharges

You are applying to the lndigency/lncentive programs and the department will determine which program you qualify for by the supporting documentation you submit.

NOTICE: Additional documentation may be requested. You will be notified in writing of the specific documentation required. Requested documentation must be received within 30 days of the date on the initial notice, to be considered as part of this application. If you are unable to respond within 30 days, you will be required to fill out and submit a new notarized application with new supporting documentation.

OATH BEFORE NOTARY PUBLIC

ENTER ADDITIONAL INFORMATION IN THIS SPACE

couNTY oF g/m &ch BEING

FIRST DULY SWORN, UNDER OATH, SAYS: THAT HE/SHE IS THE APPLICANT IN THIS ACTION AND KNOWS THE CONTENT OF THE ABOVE APPLICATION AND CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

sTATE oF £/ov-r

SUBSCRIBED A

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Signature of Notary Public

My commission/ term expires: f)~ /.), Jo)

~-~~~~~·~~~'/:-- ROSE-CHAM MCALDERON

INC-A (V2.0 07/13)

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Notary Public - State of Florida

::1 My Comm. Expires Nov 12, 2013

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Commission # EE 108623

Notary Stamp

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Page 2 of 2

Mail the original notarized form to:

~MSB

INDIGENCY/INCENTIVE APPLICATION PROCESSING PO BOX 16733- AUSTIN, TX 78761-6733

TOLL FREE (800) 688-6882

Mon- Thur BAM- 9PM, Fri BAM- 6PM Saturday BAM - 12PM

Date:

September 21, 2013

To:

Whom It May Concern:

Regarding Customer:

Dylan N. Carson 224 MW 2"d Ave, Apt 2 Delray Beach, FL 33444

To Whom It May Concern:

This letter is verification that the customer named above has an account with Wells Fargo. This account number ending in -9977, was opened 09/09/2013 and has a current balance of

$30.27.

If you need deposit information, refer to the customer named above. The account holder can provide deposit information from their monthly statements.

( ILb ~en! ~.//. y.ef)

If you have any questions please call us at 1-800-TO-WELLS (1-800-869-3557). Phone Bankers are available to assist you 24 hours a day, 7 days a week.

uely,

!::~deron~

Personal Banker II (561 )450-3052

© 2010 Wells Fargo Bank, N.A. All rights reserved. Member FDIC. DSG4236 (7-10 129971)

Wells Fargo StoreVision Platform

Page 1 of 1

Account

Wells Fargo Opportunity Checking

cci-al-app 13/prod_svp_ 253. 0. 4-svn_g

8631679977

Bank FLORIDA (287) Detail I Address I History I Statements I Stop Payments I Holds/Pledges I Overdraft/NSF Fees 1Service Fees 1Check Orders 1Transfers

Checking/Savings Account History

ISelect action

Tax Responsible Customer Additional Customers

DYLAN N CARSON None

Sole Owner

Ledger Balance

$30.27

Available Balance

$30.27

Date

09/19/13

09/18/13

09/17/13

09/16/13

09/16/13

09/16/13

09/16/13

09/16/13

09/09/13

Description

Pos Purchase - Exxonmobil Pos Boca Raton Fl 7204

00000000654605988

Pos Purchase - Exxonmobil Pos Boca Raton Fl 7204

00000000855305953

Online Transfer From Carson D Ref #ibetqrsws7 Savings Text Transfer Via Mobile

Withdrawal Made In A Branch/store Withdrawal Made In A Branch/store

Pos Purchase - Exxonmobil Pos Boca Rat Fl 7204

00000000946964914

Pos Purchase - Exxonmobil Pos Boca Rat Fl 7204

00000000456114417

Pos Purchase - Publix Super Mar 555 N Delray Beach Fl 7204

00463258833424983

Checking Opening Deposit View Deposit

WELLSFAIOOBANX,N.A.

PLAZA AT DELRAY 1500SFEDERAL HWY DELRAY BEACH, FL 33483

https://al-site1.salesandservice.wellsfargo.com/svp/accountHistorylnit.do

Check

Number

Amount

Balance

1.05

30.27

3.05

31.32

+25.00

34.37

25.00

9.37

20.00

34.37

4.28

54.37

4.30

58.65

37.05

62.95

+100.00

100.00

9/2112013