Vehicle Repair Summary

Automotive Repair Shop *

Automotive Repair Shop Contact Name (Who is completing this form?) *

First

Last

Select your automotive repair shop

Select the automotive repair shop where the repairs were completed.

Email for Automotive Repair Shop *

Client / Customer Name *

First

Last

Enter the date the vehicle was dropped off at the repair shop. *

mm/dd/yyyy

Enter the date the vehicle repairs were completed and vehicle was picked up. *

mm/dd/yyyy

Briefly describe the repairs that were completed. *

For planning purposes only, please answer the following questions.

These questions are solely for the purposes of helping Moneytalk be prepared for potential additional assistance requests as well as reminding the client of upcoming maintenance to be completed.

Are there safety related repairs that were not completed? *

Yes, there are more safety related repairs that need to be completed
No, all needed safety related repairs are complete

Briefly describe any safety related repairs that were not completed. Estimate how soon might these repairs need to be completed. *

Are there other non-safety repairs that were not completed? *

Yes, there are other non-safety related repairs that need to be completed
No, all needed repairs are complete

Briefly describe any non-safety related repairs that still need to be completed. Might any of these repairs become a safety related issue? *

Repair Payment Information

Provide the requested information about the multiple options for paying for the repairs. The rest of the information will be on the receipt you attach at the end.

Mark all the different ways the repair bill was paid. *

Donation from Moneytalk Financial Foundations
Payment plan will be used for remaining amount
Donated or discounted parts
Donations from friends or family
Donated or discounted labor
Client paid all or a portion
Donation from sub-program support
Other

Enter amount of discounted or donated parts. *

Enter name of company who donated or discounted the parts. *

Are the donated parts to be kept confidential or anonymous? *

Yes, keep confidential or anonymous
No, the company is okay with sharing their participation in this program

Enter amount of discounted or donated labor provided by automotive repair shop. *

Enter amount paid by client when vehicle was released. *

Enter amount to be paid through the payment plan. *

Enter amount donated by family or friends. *

Enter amount donated by Moneytalk Financial Foundations. *

Select sub-program supporting this vehicle repair. *

Enter amount donated by sub-program support. *

For "other", describe other method of payment *

Enter amount provided through "other" method of payment. *

Wrap-it Up

Upload a copy of the repair invoice *

Click or drag files to this area to upload. You can upload up to 10 files.

Upload a copy of estimates provided for work yet to be completed.

Click or drag files to this area to upload. You can upload up to 10 files.

If you created estimates in a separate document from the repair invoice for work that still needs to be completed, please upload it here. This will help us work with the client to be prepared to pay for these repairs and/or anticipate upcoming vehicle repair financial assistance requests.

Upload a copy of the payment plan if not already provided to MTFF

Click or drag files to this area to upload. You can upload up to 10 files.

Anything else you would like for us to know?