JOB ACCESS LOAN



Job Access LoanCombined Application and Repayment AgreementPersonal information you provide may be used for secondary purposes [Privacy Law, S. 15.04(1)(m), Wisconsin Statutes].LOAN APPLICANT INFORMATIONApplicant Name FORMTEXT ?????Applicant Address FORMTEXT ?????CASE, Claim or PIN Number FORMTEXT ?????Applicant Home Telephone Number FORMTEXT ?????Applicant Work Telephone Number FORMTEXT ?????I wish to apply for a Job Access Loan for the following purpose(s) and amount(s).Expenses Related to Starting or Keeping a JobTransportation To and From a Job HousingWork clothing, boots, etc.$ FORMTEXT ?????Car Purchase$ FORMTEXT ?????Rent$ FORMTEXT ?????Work equipment$ FORMTEXT ?????Car Repair$ FORMTEXT ?????Security Deposit$ FORMTEXT ?????Car Insurance $ FORMTEXT ?????Driver’s License Fee$ FORMTEXT ?????Job Related Relocation$ FORMTEXT ?????Fines that prevent me from obtaining a Driver’s License $ FORMTEXT ?????Other (describe) FORMTEXT ?????$ FORMTEXT ?????Total Job Access Loan Request: $ FORMTEXT ?????SIGNATURE – Applicant (or Telephonic Signature Interaction ID) FORMTEXT ?????Date Signed FORMTEXT ?????The lower half is to be completed when the loan is issued.ACKNOWLEDGEMENT OF RECEIPT OF JOB ACCESS LOAN AND TERMS OF REPAYMENTI have received a Job Access Loan of $ FORMTEXT ????? on FORMTEXT ????? and agree to repay this loan. My monthly payment will be $ FORMTEXT ????? in cash and FORMTEXT ??? hours of volunteer work in the community over FORMTEXT ????? months. My first payment is due on FORMTEXT ?????. FORMCHECKBOX Check this box to indicate an agreement of volunteer work; FORMTEXT ??? hours per month.Volunteer work in my community is valued at minimum wage. If I miss a payment or do not show proof of my volunteer work three times, I will lose this option and then the balance is due in cash. FORMCHECKBOX I acknowledge that this loan is intended to support my child or children and my family by helping me to get employment that will raise my family’s income. FORMCHECKBOX If I miss three payments or have three late payments, not necessarily in a row, the State of Wisconsin will take all or part of future State income tax refunds until the loan has been paid in full.I can make payments on my JOB ACCESS LOAN(S) electronically from a checking or savings account. If I want more information about the electronic repayment option, I can call the Public Assistance Collection Section at 1-800-943-9499 or visit the website at – Applicant (or Telephonic Signature Interaction ID) FORMTEXT ?????Date Signed FORMTEXT ????? ................
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