P.O. Box 7261
Fairfax Station, VA 22039-7261
hart90office@hart90.org Fax: 703.783.0489

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Vehicle Donation Form

Vehicle Information

Year

Color

Odometer

License plate

Make

Model

VIN number

Body style (select all that apply)

2-Door

4-Door

Hatchback

SUV

4WD

Does the vehicle run and drive as is?

Yes

No

Do you have the title?

Yes

No

Interior

Excellent

Good

Fair

Poor

Body damage (select any that apply)

Front end

Rear end

Driver side

Passenger side

Does it have any engine problems?

No

Yes

Does it have any transmission problems?

No

Yes

Does it have any tire problems?

No

Yes

Does it have any other problems?

No

Yes

Address where the vehicle is located

Special instructions




Your Information

Name

Address

Phone Number

Alternate Phone Number

Email Address

Confirm Email Address