VEHICLE DONATION PROGRAM APPLICATION:

Locate Sellers or Transfer signature line (generally in the first section or section A on the back of the title): sign your name as it appears on the front of the title. Both parties need to sign if an AND, / (slash), appear in the name on the front of the title. If you are sending an Application for Duplicate Title, there must be two signatures on the form. Names with AND, OR, /, on the original title require both signatures.

Locate the boxes for the odometer reading; print the exact reading in the boxes. (Generally vehicles older than 1995 do not need the mileage.)

If a lien holder (bank, credit union etc.) is printed on the front of the title, and is not signed off, the lien holder must sign it off or you must include the original lien release statement. You do not sign in this area.

Return the signed title and this form to: American Lung Association of Utah, 1930 South 1100 East, Salt Lake City, UT 84106. To contact us by phone, call 801-484-4456 or 1-800-LUNGUSA (1-800-586-4872). For credit for tax year 2005, titles must be received in our office or postmarked by December 31, 2005.

5. Vehicles pickup is coordinated through Dean Clark Used Cars, 1101 South Main Street, SLC, UT. If the vehicle is not picked up within 3 weeks of you sending in the application and title, call the ALAU and get a stock number. Then call Steve at 801-521-7981 to inquire about pick-up time. You will be called prior to pick-up to verify vehicle location and condition.

If vehicle is parked on the street, leave the plates on until the vehicle is picked up, and have the keys available for the person picking up the vehicle. Otherwise, remove the plates from the vehicle prior to pick-up. After you receive your donation letter, you should call the DMV and let them know you have donated your vehicle and wish to cancel your registration.

Vehicles must have 4 inflated tires and wheels, engine, transmission, keys and must be towable.

Donor agrees that once the title is received at the ALAU office, the vehicle becomes the property of the ALAU.

Signature of Donor

__________________________________

Name ________________________________________________________SS#_________________________

First Last

Mailing Address____________________________________ City ____________________Zip_______________

Home Phone:__________________ Work Phone:___________________________Cell Phone: ______________

Vehicle Information:

Year:_________Make:_______________Model:_______________Color:_____________#Doors:_____________

Vehicle Identification Number (please print very clearly)__________________________________________________

Is Vehicle Drivable? ____________Title Clear: Yes /No Plates: On/Off Are there any parts missing? _____________

Is Vehicle accessible to hauler, i.e., driveway? _______ Does the Engine Run?___________ Mileage______________

Condition of Vehicle __________________________________________________________________________

Location of vehicle____________________________________________________________________________

Other Comments:____________________________________________________________________________

Please circle and indicate where you heard about our vehicle donation program:

Television; Which Channel?______, ¨ Radio Which Station?_______, ¨ Newspaper; Which? ________, ¨ Internet; ¨ Friend Flyer_________, ¨ Billboard; Where?________, ¨ Repair Shop; Which one?______________, Donated Before; ¨ I or I have family member(s) who: (Please Circle) have: Asthma; COPD; Lung Cancer; Other Lung Disease; do or did Smoke ¨ Other_______

for ALAU use only

Date Sent____________________ WWW.DONATEYOURCAR.COM Date Received ________________