HART Car Donation

P.O. Box 7261
Fairfax Station, VA 22039-7261
703-691-HART Fax: 703-691-1730
www.hart90.org

United Way #8363
CFC-Federal #75875
CVC-Virginia #8183

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Designate HART
United Way #8363,
CFC #75875

Businesses with H.A.R.T.

Vehicle Donation Pick-Up Request

Please complete this form and transmit to HART
Thank you for your donation!

Date:

Donor Information
Name:

Address:

Phone #: Alternative #:

Email:

Vehicle Location (if different than above):

City:     State:     Zip:

Vehicle Information

Year:

Make:

Model:

VIN:

License:

Odometer:

Please check all that apply: 2-Door
4-Door
Station-Wagon
4-Wheel-Drive

Does the vehicle run and drive as is?: Yes    No,   Explain

Do you have the title?: Yes    No,   Explain

Interior: Body Damage: Problems:

Excellent None None

Good Front End Engine

Fair Rear End
Transmission

Poor Driver Side Tires

Passenger Side Other

Special Instructions

Before you click submit, please print the completed donation form and save for your records.

Contact Information
Telephone 703.691.HART (703.691.4278) Postal address P. O. Box 7261 Fairfax Station, VA 22039-7261	FAX 703.691.1730 Electronic mail General Information: HART Office Website: Webmaster Unanswered Email

Contact Information