Lienholder: Account #:

        Referred By:

        Address:

        City: State: Zip:

        Phone:

        Fax: WATS:

        Collector: E-mail:

        Debtor:

        Address:

        City: State:

        Zip:

        Phone:

        DOB: Soc Sec #:

        Employment Information:

        POE:

        Address:

        City: State: Zip:

        Phone:

        Co-Debtor:

        Co-Debtor Address:

        Co-Debtor City: Co-Debtor State:

        Co-Debtor Zip:

        Co-Debtor Phone:

        Co-Debtor DOB:

        Co-Debtor Soc Sec #:

        Co-Debtor Employment Information:

        Co-Debtor POE:

        Co-Debtor Address:

        Co-Debtor City: Co-Debtor State:

        Co-Debtor Zip:

        Co-Debtor Phone:

        Collateral Information

        YearMakeModel

        VIN#:

        ColorPlate State

        Key Codes:

        Loan #: Loan Balance:

        Due Date: Mo. Pymt:

      Assignment Type: 

      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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