United Society
Vehicle donation eligibility application 

I. Personal Information
Name:   D.O.B.
Address: Phone:
City:         Email:
State:    Zip Code:  

II. Other Persons Living in Household

Number of People in Household 

Name

Age

Relationship
 

III. Monthly Income / Employment Information
Type of Income
 Self Spouse Household Members Total
Gross Wages

Unemployment

Workers' Compensation
Pension
Social Security
Work First / TANF
Disability
Other
         
I hereby certify that the aforementioned information is true to the best of my knowledge.
Print Name:
Date: