CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS

Consumer Assistance Program Application

Receive up to $1,500 to Retire Your Vehicle
Para obtener una solicitud en español, llámenos al 800.952.5210.

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

1. Program Option

Vehicle Retirement - Income eligible vehicle owners may receive $1,500 to retire their vehicle. All others may receive $1,000.

$1500 (Will require income verification documentation)
$1000

Repair Assistance - Income eligible vehicle owners may receive up to $500 in emissions-related repairs if their vehicle fails a biennial Smog Check inspection.

For a complete list of eligibility requirements, please visit www.smogcheck.ca.gov.

2. Registered Owner Information

Last Name
*

First Name
*

M.I.

Driver License or I.D. #

Date of Birth

Mailing Address
*

APT.

City
*

State

Zip
*

Daytime Phone #

2a. Joint Registered Owner Information (if applicable)

Last Name
*

First Name

M.I.

Driver License or I.D. #
*

Date of Birth

Last Name
*

First Name

M.I.

Driver License or I.D. #
*

Date of Birth

Last Name
*

First Name

M.I.

Driver License or I.D. #
*

Date of Birth

3. Vehicle Information

Vehicle Year
*

Vehicle Make
*

Vehicle Model
*

Vehicle Identification # (VIN)
*

California License Plate #
*

4. Income Verification

Number of people (Include Yourself) living in the household is: *

Gross Household income is: $ *

MonthlyYearly *

Program Option

None None

Registered Owner Information

Last Name
None

First Name
None

M.I.
None

Driver License or I.D.#
None

Date of Birth
None

Mailing Address
None

APT.
None

City
None

State
None

Zip
None

Daytime Phone #
None

Joint Registered Owner Information

Last Name
None

First Name
None

M.I.
None

Driver License or I.D. #
None

Date of Birth
None

Last Name
None

First Name
None

M.I.
None

Driver License or I.D. #
None

Date of Birth
None

Last Name
None

First Name
None

M.I.
None

Driver License or I.D. #
None

Date of Birth
None

Vehicle Information

Vehicle Year
None

Vehicle Make
None

Vehicle Model
None

Vehicle Identification # (VIN)
None

California License Plate #
None

Income Verification

Number of people (Include Yourself) living in the household is: None

Gross Household income is: $ None Per None

I acknowledge that the information provided on this application will be used to assess and verify my eligibility for assistance, and upon request, I may be required to provide documentation to the Bureau of Automotive Repair verifying household income. 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 in addition to civil penalties, and that I will not be eligible to receive future assistance in the Consumer Assistance Program (CAP). I further understand and agree that if my vehicle does not meet all program eligibility requirements, it will not be allowed into the CAP.

The checking of this box serves as an original electronic signature for all registered owners of the named vehicle. It further serves as an acknowledgement by all registered owners that the information provided is for the purpose of verifying eligibility for participation in the Consumer Assistance Program.

Vehicle retirement and repair assistance can only be performed at State approved facilities. CAP will not reimburse consumers for work performed prior to the approval of an application. Financial assistance is based on the availability of funds.

Questions? Please call 866.272.9642 or visit www.smogcheck.ca.gov.

Pursuant to Section 1798.17 of the Civil Code (Information Practices Act), the Director of the Department of Consumer Affairs is responsible for maintaining the information in this application. Information may be transferred to other governmental agencies if required. Individuals have the right to review the records maintained on them by the agency, unless the records are exempted by Section 1798.40 of the Civil Code.

CAP/APP (07/12)