The Arc of Southern Maryland Car Donation Form

* Submitter's Name:

* Submitter's Email Address:

* I would like the proceeds of the sale of my vehicle to benefit: The Arc of Southern Maryland

Name as it appears on title:

Last Name:

First Name:

Last Name:

First Name:

Company Name:

Current Address:

Cross Street:

State:

Home Phone:

Work Phone:

Cell Phone:

Is the vehicle located at the above address? If not, indicate car or vehicle location for free towing or pickup. Location Name (i.e. private residence, Smith's Repair Shop, etc.)

Current Address:

State:

Contact Person:

Contact Phone: Vehicle Information

Model:

# Doors:

Mileage:

Color: Does your car or vehicle run:

No To maximize the value from the sale of your vehicle, could you describe:

Condition of Interior:

Condition of Exterior:

Mechanical Condition (please elaborate): Help prepare us to tow your car or vehicle:

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 mentioned, 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 The Arc?

How were you referred to The Arc?

We welcome your comments in the space below. * Indicates Response Required