LIENHOLDER
ADDRESS
CITY
STATE
ZIP
PHONE	EXT
FAX
EMAIL
COLLECTOR

 

DEBTOR
ADDRESS
CITY
STATE
ZIP
PHONE	EXT
FAX
EMAIL
SS#/DOB

 

EMPLOYMENT
ADDRESS
CITY
STATE
ZIP
PHONE	EXT
FAX

 

COLLATERAL YR, MAKE, MODEL
PLATE, STATE & COLOR
KEY NUMBERS
VEHICLE IDENTIFICATION #	Be sure to include all 17 numbers

 

LOAN NUMBER
PAST DUE DATE
MONTHLY PAYMENT
LOAN BALANCE
ASSIGNMENT TYPE	Involuntary Voluntary Contact and Collect Condition Report DMV MVR

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