Form 2432, CLASS and DBMD Program Vehicle Evaluation

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Effective Date

2/2026
2432.pdf

Instructions

Updated: 2/2026

CLASS Note: The term person when used in this form refers to an individual per 26 Texas Administrative Code (TAC) Chapter 259, Subchapter A Definitions, Description of Services and Excluded Services.

DBMD Note: The term person when used in this form refers to an individual per 26 TAC Chapter 260, Subchapter A, Definitions, Description of Services and Excluded Services.

Purpose

Form 2432 is completed when a person receiving Community Living Assistance and Support Services (CLASS) Program, Deaf Blind with Multiple Disabilities (DBMD) Program or Community First Choice (CFC) services requests a modification or an addition to the primary transportation vehicle as described in:

  • Appendix I, Adaptive Aids, No. 10 Modifications/Additions to Primary Transportation Vehicles in the CLASS Provider Manual or
  • section 1000, Adaptive Aids/Vehicle Modification Services No. 9 Modification/Additions to Primary Transportation Vehicles, in the DBMD Program Manual.

The form is used to determine if and verify that the vehicle meets the criteria described in:

CLASS only: The vehicle must be less than five years old and mileage must be less than 50,000 miles. Or the vehicle must pass an independent evaluation performed by an automotive technician certified by the National Institute for Automotive Service Excellence (ASE).

The vehicle's owner will be responsible for any payment required to conduct the evaluation.

DBMD only: The vehicle must be less than four years old and mileage must be less than 75,000 miles. Or the program provider must obtain a written evaluation by an ASE certified technician to ensure the sound mechanical condition of all major components of the vehicle.

Include the actual cost of the written evaluation as part of the invoice, cost not to exceed $150.

Texas Health and Human Services may pay for repair and maintenance of some Adaptive Aid equipment. HHSC will not, however, pay for the cost of repairs or adjustments to the vehicle.

Procedures

When to Prepare

An ASE certified automotive technician completes Form 2432 to document that a vehicle is functioning in a manner that allows safe operation.

Form Retention

The direct services agency (DSA) or DBMD provider must keep the original form in the person's case record and provide a copy to the case management agency if applicable.

The DSA or DBMD provider must keep this form per record retention requirements documented in the CLASS Provider Manual or DBMD Program Manual.

Detailed Instructions

Is the vehicle registration current?: Check Yes or No to indicate if vehicle registration is current.

Note: If the response is No, funding will not be approved. However, a completed vehicle evaluation is still required to identify any other potential vehicle issues.

Vehicle Information

Name of CLASS or DBMD Person: Enter the name of the CLASS or DBMD person.

Name of Registered Owner of Vehicle: Enter the registered vehicle owner’s name. If the owner is not the person enrolled in CLASS, also include the name of the person enrolled in CLASS program.

Relationship of Vehicle Owner to CLASS or DBMD Person: Enter the relationship of the owner to the person receiving CLASS or DBMD services – self, parent, sibling, cousin, etc.

Make, Model, Year of Vehicle: Enter the vehicle manufacturer name, the vehicle model and vehicle year.

Vehicle ID No.: Enter the vehicle identification number (VIN).

License Plate No.: Enter the vehicle license plate information and the state that issued the license plate.

Mileage: Enter the mileage shown on the vehicle odometer.

IPC Effective Date: Fill in the effective dates for the current IPC year.

Note: This form is only valid for the IPC year it is completed.

Vehicle Inspection

Mechanical Areas: Evaluate each specified mechanical area to determine if each area is functioning sufficiently to allow for safe operation. If an area passes, no comment is necessary. If an area fails, state the specific work needed to correct the problem.

Additional comments: Document any more comments to include overall condition of vehicle, overall vehicle maintenance and general appearance. Describe any indications vehicle has been involved in an accident or has flood damage.

Note: Any identified failed areas must be documented with corrective comments and a follow-up evaluation will be necessary. The follow-up evaluation should confirm that all previously failed areas have been successfully addressed.

ASE Technician Information

Name of Automotive Repair Shop: Enter the name of the automotive repair shop.

Area Code and Phone No.: Enter the area code and phone number of the automotive repair shop.

Street Address, City and ZIP Code: Enter the address of the repair shop.

ASE Certified Technician’s Printed Name: Enter the name of the ASE certified technician who performed the inspection.

ASE Technician’s Certification No.: Enter the ASE’s certification number.

ASE Technician’s Signature: The ASE certified automotive technician signs the form.

Date of evaluation: Enter the date the vehicle was evaluated.