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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	Number of children **
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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