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January 6, 2009

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Vehicle Donation Form

Personal Information

E-mail Address:

Submitter's Name:

Donor's Name(s) as it appears on the the title:

Last Name:

First Name:

Last Name:

First Name:

Company Name:

Current Address:

Cross Street:

City:

State:

Zip:

* A phone number is required in order to submit this form *

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

Is the vehicle located at the above address?

If not, indicate vehicle location below

Location name:
(i.e. private residence, Smith's Repair Shop, etc.)

Current Address:

City:

State:

Zip:

Contact Person:

Contact Phone:
Vehicle Information

Year:
Make:
Model:
VIN:
# Doors:   
Color:
Mileage:
Does your vehicle run? 

To maximize the value from the sale of your vehicle, could you describe:

Condition of Interior:
Condition of Exterior:
Mechanical Condition
(please elaborate):

Do you have keys?

How do you rate the tires? 

Are the tires inflated?

Does the vehicle have a battery?

Is vehicle accessible to tow truck and not parked in garage or grassy area ? 

Title number:

Title state:

Title Control Number:

Is there or has there ever been a lien on the vehicle?

On the front of the title, if there is a financial institution listed, you will be
required to have a lien release

When your vehicle is picked up by our towing company, where would you like us to leave the receipt? (Example: mailbox, under door, mail to me).
Have you heard of UCP?

How were you referred to UCP?:

Affiliate which you want to donate you vehicle to?:

We welcome your comments in the space below.

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