Kidney Cars

Kidney Car Assessment Form

 Personal Information
  Registered Owner(s) Last Name:
  Registered Owner(s) First Name:
  Salutation: Mr.  Mrs.  Ms.
  Address:
  City:
  State:
  Zipcode:
  Home Phone:
  Day/Cell Phone:
  Email:
 Survey Information
  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:
 
 
  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
 
  Has the vehicle been in an accident? Yes  No
 
  Did the Insurance Company total (salvage) the car? Yes  No
 
 Car Condition
 
  Please indicate the condition of the following:
 
  Battery: Good  Fair  Poor
 
  A/C: Good  Fair  Poor
 
  Transmission: Good  Fair  Poor
 
  Engine: Good  Fair  Poor
 
  Tires: Good  Fair  Poor
 
  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
 Car Location Information
 
Address:
City:
Zip Code:
Notes:
  Contact Person(CP):
  Contact Phone #:
  Are all four tires on the vehicle and inflated? Yes  No
  Is the car on a steep incline? Yes  No
  Is your car accessible to tow truck? Yes  No
  Is your car at least 4 feet from any structures? Yes  No
  Are all personal items removed? Yes  No
ALL CARS ARE USUALLY PICKED UP MONDAY THROUGH FRIDAY, EXCLUDING HOLIDAYS PLEASE ALLOW SEVEN TO TEN BUSINESS DAYS AFTER PROCESSING.

Please Read Carefully and Acknowledge Below

I have donated my vehicle to the National Kidney Foundation of Maryland (NKF-MD). I release ownership with the understanding that the vehicle will be sold to raise funds to fight kidney disease in Maryland. My vehicle meets the minimum acceptance requirements below:

  1. The complete engine, transmission and parts are on the vehicle, attached, and in their proper place*;
  2. All four tires are in place and fully inflated. The wheels are not locked and will not be removed after donation;
  3. The vehicle has never been on fire, had flood damage or been submerged in water;
  4. The car hasn’t been sitting outside for more than 6 months, and/or located where it has partially sunk into the ground;
  5. There are no additional engine parts, trash, furniture or items inside the vehicle;

My car is being donated free of any unpaid violations, fines or liens (including fines associated with the theft of my car) and will remain so prior to NKF-MD taking physical possession of it. If I am asking NKF-MD to tow my vehicle, I understand that NKF-MD may require up to five working days after receiving my properly signed title in which to tow my vehicle. If my vehicle is cited or removed prior to NKF-MD’s tow, I understand that NKF-MD cannot tow my vehicle until I pay all fees. I understand that if my vehicle is not accessible to the tow company on the agreed-upon dates and location, I must pay for the dry-run fee prior to having a second tow truck dispatched. 1) The car must have a minimum of four feet of clearance on all sides, 2) The car must be on pavement or cement. (Tow companies are prohibited from physically pushing vehicles to a place where it will be accessible). I understand that if the MVA mails me a citation for an offense occurring after donation, NKF-MD will clear the citation. I understand that any parking decals or personal belongings left in or on my vehicle will not be recoverable. If I have Veteran Plates, it is my responsibility to have them removed and assigned to a new vehicle or placed in storage at MVA prior to donation. I understand that if my vehicle is being picked-up from an auto repair shop, that it is my responsibility to ensure that no parts have been removed and that NKF-MD may refuse to tow my vehicle if parts have been removed.*

I understand that if I have gotten a duplicate title issued, I must give NKF-MD the most recently issued title. I must also give NKF-MD a transferable, Maryland State, non-defaced title. If I cannot produce a transferable title, NKF-MD may reject my donation. In order to receive a tax benefit, I must itemize my taxes. I understand that if I have already depreciated the value of my vehicle or received an insurance settlement for its value, I may not qualify for a tax deduction. I hold harmless and agree not to pursue any legal action against NKF-MD, its board of directors or agents for any loss or liability that may be incurred as a result of my donation. NKF-MD reserves the final right to refuse the donation of any vehicle.

I understand that I will receive notification of my tax deduction within 30 days of the sale. NKF-MD cannot guarantee any selling price for any vehicle. It may take up to 60 days or longer to sell your vehicle and for you to receive notification of your tax deduction.

I understand this agreement *

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