UCP of Eastern Connecticut: Vehicle Donation Program

Vehicle Donation Form

Field marked with a * required fields.

Submitter's Name: *

E-mail Address:

Do you wish to donate your vehicle to support the work of UCP or to one of UCP's local affiliates: *
	National Office
	Affiliate
Affiliate to which you want to donate your vehicle?:

Personal Information

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:

Please select one: *
Home Phone:	Work Phone:
Cell Phone:	Other Phone:

Vehicle Location

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:

Number of 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?

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).

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

Other Information

How were you referred to UCP?:

We welcome your comments in the space below.

Yes, I am interested in receiving updates on UCP's work via e-mail?

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Vehicle Donation Form