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Recycle Utah Cars Donation Sheet

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					                         Recycle Utah Car Donation Sheet
                                                      Please MAIL with correct signed title to:
                                    Recycle Utah    P.O. Box 682998    Park City, UT. 84068        (435) 649 9698
                                                               Fax (435) 658-1530
1) Donor Name: _____________________________________________________________________________________
2) Mailing Address: __________________________________________________________________________
   City: ______________________________________State: _______________________Zip:_______________
3) Home Phone: ________________________________________Daytime Phone: ________________________
4) Year of Vehicle: ________Vehicle Make: _____________________VIN# _____________________________
5) Vehicle Model: _____________________________Color: _________________________________________
6) Is the vehicle drivable? _______________________Approximate Mileage: ____________________________
   Check one:          General Interior Condition                 Poor          Fair         Good            Excellent
                       General Exterior Condition                 Poor          Fair         Good            Excellent
7) Please list all known mechanical problems:______________________________________________________
   _________________________________________________________________________________________
9) Is the vehicle missing any parts? If so, which? ___________________________________________________
   _________________________________________________________________________________________
10) Please indicate the number of ________weeks _______months ________or years the vehicle has been parked.
11) Does the vehicle have four (4) inflated tires? ____________________________________________________
12) Vehicle location: __________________________________________________________________________
   ________________________________________________________________________________________
                                       (Please include coordinates for named streets and city where vehicle is located)

13) Special pickup instructions: __________________________________________________________________
   _________________________________________________________________________________________
   ____________________________________________________________________________
14) How did you hear about the Recycle Utah Car Donation program? ___________________________________
   ________________________________________________________________________________________
                                                 Statement of Understanding and Limited Power of Attorney
     I acknowledge that by signing the vehicle title and sending it to Recycle Utah, I am releasing ownership of the vehicle. I understand
     that the vehicle will be towed away, and that I am responsible to remove all personal belongings and the license plates prior to
     vehicle removal. I will not hold Recycle Utah responsible for any items left inside of the vehicle.

     I appoint and constitute Recycle Utah and its officers and authorized employees to execute all Certificate of Title;
     Federal Odometer Statements; and such other documents to convey clear title.

     X_____________________________________________________________                               ___________________________________
      Donor’s Signature                                                                           Date
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posted:2/27/2010
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