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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

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