Name of Registered Owner of Vehicle *

First Name

Last Name

Mailing Address *

FOR TAX RECEIPT PURPOSES (if applicable).

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Day Time Phone Number *

(###)

###

####

Agreement *

By submitting this form, I declare that I am the legal owner of this vehicle and release it to Youth for Christ Association /Worth Auto as a donation. Worth Auto is authorized to pick up the vehicle identified (if pick up is applicable) and may dispose of it as they see fit. This vehicle is free of all liens and encumbrances.

Agree

Disagree