| Lienholder: |
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| Address: |
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| City: |
State: Zip: |
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| Phone: |
Extension:
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Fax:
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| E-mail: |
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| Collector: |
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Debtor:
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Address:
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City:
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State:
Zip: |
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Phone:
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Extension:
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| Fax: |
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E-mail:
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| Social Security Number and
Date of Birth: |
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| Employment: |
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| Address: |
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| City: |
State:
Zip: |
| Phone: |
Extension:
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| Fax: |
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Collateral
Year, Make
& Model: |
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| Plate, State & Color:
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| Key Numbers: |
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| Vehicle Identification Number:
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| Loan #: |
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| Past Due Date: |
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| Monthly Payment: |
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| Loan
Balance: |
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| Assignment Type: |
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| 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. |
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| 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.
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| Authorized by: |
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| Date: |
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