Wheels for Success Donation Form

Contact Info	Last Name:	First Name:	Email:
	Mailing Address:	City:	State:	Zip:
	Home Phone:	Contact Person:	Contact Phone:
	Work Phone:	Cell Phone:	Fax:
	The IRS now requires us to collect your Social Security Number for tax reporting purposes. This information is kept confidential; however, it is required for us to process the car donation.
Vehicle Info	Vehicle Location (city,state,zip):
	Year:	Make:
	Model:	Mileage: (if available)
	VIN: (if available)	Clear Title? Yes No	2 4 # of doors
	Title State:	Transmission Automatic Manual	Do Vehicle Run? Yes No
	Color:	Is it a 4x4? Yes No	Is the engine mechanically sound? Yes No Is the transmission sound? Yes No
Vehicle Details	Describe Mechanical Problems in detail:
	Describe Body (rust, cracked windows, dents, paint flaws?):
	Describe Interior (seats, headliner, dash, etc.):
	Describe any Fluid Leaks (motor oil, transmission, coolant, power steering, brakes, etc.):
	California vehicles only: Is your vehicle currently smog certified? Yes No
	Do you consider your vehicle roadworthy enough to provide reliable transportation to a disadvantaged person? Yes No
	On a scale of 1-5, with 5 being excellent, rate the vehicle's condition: mechanical: 1 2 3 4 5 body: 1 2 3 4 5 interior: 1 2 3 4 5 brakes: 1 2 3 4 5 tires: 1 2 3 4 5
	How did you hear about Wheels for Success? ( i.e. xyz agency, newspaper, radio, internet, friend, etc.)
	Comments / Special Instructions:

Please note that all cars are not awarded to recipients. It depends on the condition, year and mileage of the vehicle. If your car cannot be used it will be sold and 100% of the funds received will be used to repair other cars. Based on the fact that the vast majority of donated vehicles are not eligible to be WTS program cars (The gift of Love, Inc. Cars bases its decisions on many factors including, but not limited to, year, make, model, mileage, condition, location, recipient, repair and funding limitations.) and since placing a vehicle with an individual is the exception rather than the rule, donors should assume that their vehicle will be sold at auction with the proceeds returning to the gift of Love, Inc Wheels to Success, Inc.(unless notified in writing that their vehicle will be provided to a disadvantaged person). Although most of the vehicles donated are not of sufficient quality to be WTS program cars, The Gift of Love, Inc. appreciates each and every car donation as they all help to fulfill our missions! Learn more about how to help others with your car donation today.