1. 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.
  1. Locate the boxes for the odometer reading; print the exact reading in the boxes.  (Generally vehicles older than 1995 do not need the mileage.)
  1. 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.
  1. 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.
  1. 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.
  1. Vehicles must have 4 inflated tires and wheels, engine, transmission, keys and must be towable.
  1. 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:
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 ________________
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