Name (First and Last):

Street Address:

City:

State:

Zip:

Cell phone:

Daytime Phone:

e-mail address:
(This is required)
Please note: A full e-mail address looks something like this:

JohnJones@aol.com or Janie133@prodigy.net.

Make

Model Description

Year

Approx. Mileage

Plate Number

VIN
(Vehicle Identification Number)

Condition of body including any damage.
Please be as specific as possible. If there is damage please describe exactly what parts are damaged and how much.

Condition of interior including any damage.
Please be as specific as possible.
Please describe and damage to seats, instrument panel, etc.

Does the automobile run/drive well?
When was the auto last running well?
(if not, please describe what is known about its running condition.)

Is the Certificate of Title in your possession? Please write here exactly how the name(s) appear on the title
Are there any liens (loans) against the title?

Is your registration current? If not, what year did you last pay your registration fee?

Location of automobile & contact person.

(Please note, if your automobile is in a different location than your above address, please give that address here fully including city and zip code as well as the name and phone number of the contact person if available.)

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If you have any difficulty with this form you can use any of the following car or automobile donate forms:

| Donate Form | Donate Form | Donate Form | Donate Form | Donate Form |
| Donate Form |Donate Form | Donate Form | Donate Form |