Kidney Cars

Kidney Car Assessment Form

 Personal Information
  Registered Owner(s) Last Name:
  Registered Owner(s) First Name:
  Salutation: Mr.  Mrs.  Ms.
  Day Phone:
  Cell Phone:
  Address1:
  Address2:
  City:
  State:
  Zipcode:
  Email:
 Survey Information
  Why are you donating your car?
  I have a relative with kidney disease I know someone with kidney disease
  I itemize my taxes and would like a tax deduction for my donation I'm moving
  To avoid the hassles of selling it I am buying or bought another car
  I want to support the National Kidney Foundation of Maryland Other   
  How did you hear about Kidney cars?
  Radio Station TV Station
  Print Publication Word Of Mouth
  Billboard Flyer
  Donor Other
 Vehicle Information
 
  Year:         Make: Model:             
 
  # of Doors: Color: Type of Vehicle:
 
  Reg. Expiration Date: (mm/yy)
 
  Odometer Reading:
 
  Is Your Odometer Working? Yes  No
 
  Has your odometer turned over? ( i.e. reads 25,000 but is really 125,000?) Yes  No
 
  My car is able to drive for a short distance: Yes  No
 
  Transmission: Automatic  Manual  4WD
 
  Cylinders: 4 cyl  6 cyl  8 cyl
 
  Has the vehicle been in an accident? Yes  No
 
  Did the Insurance Company total (salvage) the car? Yes  No
 
  Does the Title say Insurance Salvaged Rebuilt Engine on it? Yes  No
 
  Does your car have Military or special parking stickers? (If yes, remove prior to pickup). Yes  No
 
  Does your car have Veteran Plates? (If yes, transfer or store them prior to pickup). Yes  No
 
 Car Condition
 
  How much do you think your vehicle is worth?
 
  Are you aware of any repairs that your car might need? (list)
 
  Do you have an estimate or idea of what it will cost to fix?
 
  What repairs have you made recently on the car?
 
  Please indicate the condition of the following:
 
  Battery: Good  Fair  Poor
 
  A/C: Good  Fair  Poor
 
  If A/C not working, is it blowing warm air? Yes  No
 
  Transmission: Good  Fair  Poor
 
  Engine: Good  Fair  Poor
 
  Tires: Good  Fair  Poor
 
  Describe Body, Paint and Interior
 
  Any cracks or chips in the glass? Yes  No
 
  How would you describe your car's paint job? Good  Fair  Poor
 
  Any big dents or dings? Yes  No
 
  If yes, explain:
 
  Any rust on the car? No Rust  0-10%  11-30%
    31-50%  51%+
 
  Are there any leaks in the car? Yes  No
 
     If yes, where:
 
  How would you describe your car's interior ? Good  Fair  Poor
 
  Cracks in dash? Yes  No
 
  List Features
 
  Upholstery: Leather  Cloth  Other
 
  Power Steering   
 
  Power Windows  (work?)Yes  No
 
  Power Locks  (work?)Yes  No
 
  Power Seats  (work?)Yes  No
 
  Sound System: AM  AM/FM  Cassette  CD
 
 
Cruise Control  Tilt Wheel  Other 
 

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