SICSA · Vehicle Donation Contract

Contact Information

Date of Contribution

*

(mm/dd/yyyy)

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Preferred Phone

*

Alternate Phone

Email

*

Verify Email

*

How did you hear about SICSA's Car Donation Program?

*

Vehicle Information

Title Available

*

Yes

No

Name on Title

*

Year

*

Make

*

Model

*

Color

*

Mileage

*

VIN

*

Vehicle Type

*

2 Door

4 Door

Other

Does it run?

*

Yes

No

Can it drive 20 miles?

*

Yes

No

Body Condition

*

Good

Fair

Poor

If Other, please describe

*

Does the vehicle need to be towed to SICSA?

*

Yes

No

A Taxpayer ID number is a requirement of this form.

This field is optional. If you prefer to give your TIN securely, please call 937.294.6505 ext 13 after completing this form.

Thank you!

Please note, the IRS requires form 1098c to be completed in order to claim a tax deduction for vehicle contributions greater than $500.