Please remember to fill out all the fields. Missing information will result in an immediate declination of your request.

To minimize delays processing your request, please review our request guidelines.

Submit a Request

Client Information

Client First name **	Client Last Name **
Client Email Address **	Client Phone *
Birthday *	Gender Male Female
Drivers License Number **	Drivers License State **
Address *	City *
State/Province *	ZIP/Postal *

Caseworker Information

First Name **	Last Name **
Email Address **	Caseworker Phone *
Caseworker Time with Client * Less than 1 month 1 to 12 months More than 1 year

Request Details

Request Type * Vehicle Donation Vehicle Repair	Highly Confidential Yes No
Impact statement **

Repair Request Details

Car licensed and insured by Client Car licensed and insured by Client NoCar licensed and insured by Client Yes
VIN (Vehicle Identification Number) *	Year *
Make *	Model *
Color *	Mileage **
License plate number *	License plate state *
Vehicle currently drivable? If no, include details in Summary Unknown Yes No
Vehicle Location *
Summary of vehicle issues *
Needs tires Needs tires NoNeeds tires Yes	Tire size *

Vehicle Donation Request Details

Client owns a vehicle, or has one available? (If yes, please explain) Client owns a vehicle, or has one available? (If yes, please explain) NoClient owns a vehicle, or has one available? (If yes, please explain) Yes	Client owns vehicle Explanation *
Has funds for registration Has funds for registration NoHas funds for registration Yes
Number of people in family **	Number of children **
Ages of children	Number of car seats **
Can drive manual Unknown Yes No	Interlock device required Yes No
Specific needs *

Generate a new imagePlay the audio code

Enter the code from the image