Contributor’s Name _____________________________________________

                                Home Telephone _______________   Work Telephone _________________

                                Address ______________________________________________________

                                Vehicle Location _______________________________________________

                                Major Cross Streets _____________________________________________

                                Is this a : House ____   Apartment ____   Business(Name) _______________

                                Make _________________  Model ____________________   Year ______

                                Color ___________ License # _____________ Vehicle VIN# ___________

                                Is the vehicle registered in your name? Yes _____ No _____

                                Type of Title Document _________________________________________

                                Description of Vehicle Condition:

                                A. Complete with tires/wheels/engine/transmission? Yes ___ No ___

                                    Tires flat? Yes ____ No ____

                                    Runs? Yes ____ No ____

                                B. Has the vehicle been in an accident and/or burned? Yes __ No __

                                C. Have all trash and personal belongs been removed? Yes __ No __

                                D. Does all the vehicle have keys? Yes __ No __