Donate Your Car, Truck, Van, or boat (with trailer) to the lifeCars™ program of the Kidney & Urology Foundation of America, Inc.

To use our online form, you must be donating a 1990 vehicle or newer (running or not) in one of the counties listed below. If your vehicle is not located in one of the counties listed below, please call 1.800.633.6628 and we will be happy to assist you with your donation.

In what County do you live?

How did you hear about us? Please Specify:

Email Address: Male Female

Last Name: First Name:

Address 1: Apt/Suite:

Address 2:

City State Zip

Daytime Telephone #: Fax #:

Name on Title:

Year: Make: Model:

Color: Mileage: # of Doors: # of Seats If "Other" please specify

# of Cylinders Other (please specify):

Is the car driveable? Yes No When was the car last driven?

Is the inspection current? Yes No

How would you rate the interior of the vehicle? Good Fair Poor

How would you rate the exterior of the vehicle?

A. Dents: Minor Moderate Extensive

B. Rust: Minor Moderate Extensive

What is the address of the vehicle if different from the above address?

Please press return at the end of each line...

Please list any problems or comments with regard to your vehicle:

Please press return at the end of each line...