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Lienholder:
Billing Address:
City: State: Zip:
Phone: Extension: Fax:
Assignee:
E-mail:
Collateral VIN #:
Year, Make & Model:
Plate, State & Color:
Key Code: Brake Code:
Account #:
Past Due Date:
Monthly Payment: Loan Balance:
Debtor:
Address:
City: State: Zip:
Home Phone:
Cell Phone:
Social Security Number and Date of Birth:
Employment:
Address:
City: State: Zip:
Phone: Extension: Fax:
Assignment Type:
Note: Should you have any information regarding family members, relatives of the debtor, or any unique or defining information that would be helpful in aiding us in the recovery of your vehicle, please enter that information in the "Instructions" space below.
This is your authorization to act as our agent to collect or repossess the above collateral. We agree to indemnify and hold you harmless from and against any and all claims, damages, losses and actions including reasonable attorney fees, resulting from and arising out of your efforts to collect and or repossess claims, except, however, as such may be caused by or arise out of negligence or unauthorized acts on the part of you, your company, its officers, employees or its agents.
Authorized by:Date:
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