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Legal or Forwarding Agent/Owner Information:

Return Email:
Legal Owner:
Owner's Address:
Assigned By: Date:
Phone: Extension:
Fax: Watts or 800 #:

Debtor Information:
Debtors Name:
Home Address:
Work Address:
Home Phone: Work Phone:
DOB: SS #:
Spouse's Name:
Spouse's DOB: Spouse's SS #:

Collateral Property Information:
Year: Make:
Model: Color:
License #: State:
Ignition Key #: Trunk Key #:
VIN #:

Loan Information:
Loan Number: Balance:
Past Due Date: Monthly Payment:
Past Due Amount:
Assignment Type:

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Special Instructions:

Storage Instructions:

This is authorization to act as our agent to collect or repossess the above collateral. We agree to indemnify, and hold 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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