Drink at The Well — Vehicle Donation

Drink at The Well — Vehicle Donation
1. DONOR INFORMATION
Full Name

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
2. VEHICLE SPECIFICATIONS & CONDITION
Year
Make
Model
Color
Odometer
Overall Condition
Runs and Drives?
Tires Inflated / Rolling?
Keys Included?
Title in Hand?
Vehicle Identification Number (VIN)
3. PICKUP & LOCATION DETAILS
Collect Vehicle at donor address?
Pickup Location Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Special Pickup Notes
4. TITLE & TAX ACKNOWLEDGMENT
Name(s) Printed on Front of Title

First NameMiddle NameLast Name
Free & Clear of Liens/Loans?
Do NOT sign or date the back of the vehicle title until you receive explicit placement instructions from our intake coordinator or authorized towing representative.
By signing below, I certify that I am the legal owner (or duly authorized agent) of the vehicle described above and authorize Drink at The Well to process and accept this vehicle donation. An official written tax acknowledgment (including IRS Form 1098-C where applicable) will be issued upon processing or final sale.
Donor Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I consent to electronic signing
Thank you for supporting Drink at The Well | Empowering Women. Renewing Hope.

Questions about donating a vehicle? Call 410-370-8888
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