Donation Intake Form

Donor Information
Name Leigh Dixon County Mays
(Please explain if different from name on title.)

Address None City Chicago State IL Zip

Home phone Cell phone (optional) 512 783 9751

Social security number* ***-**-7054 Email (optional) Hesachi33@gmail.com

*Please note that if your vehicle sells for more than $500, we must have your social security number if you wish to claim your full tax deduction. See
enclosed brochure for additional details.

Vehicle Information
Year 2013 Make Chevrolet Model Tahoe 2WD Color Tan
Address of vehicle City Chicago State Il Zip
(If different from address provided above.)

Location of keys With vehicle Call ahead required?* Yes X No

*Please note that you do not need to be present when your vehicle is towed, and requiring a call ahead may significantly delay vehicle pickup.

Engine Starts: X YES NO (If “NO” please explain: )

Vehicle is drivable: X YES NO (If “NO” please explain: )

Transmission issues: YES X NO (If “YES” please explain: )

Electrical issues: X YES NO (If “YES” please explain: )

Body issues: X YES NO (If “YES” please explain: Dented front end , headlamp nonworking)

Please provide any additional information you can about the vehicle’s condition (recent repair work, flat tire(s), etc.)

How did you learn about us?

 TV  Goodwill store, truck,  Newspaper
or employee
 Radio  Direct mail
 Goodwill donation receipt
 Outdoor/billboard  Vehicle donor
 Phone book
 Website  Other: -
 Auto repair shop
 Family/friends -

Why did you choose Goodwill over other vehicle donation options? Na

Goodwill Cars to Work is a program of Goodwill Industries of Kentucky, Inc. | www.goodwillkycarstowork.org