* = Required Fields

Lien Holder:

Client Code: Order Date:

Address:

City: State: Zip:

Phone: Ext.: Fax:

Submitted By:* E-mail:*

Last Name: First Name:

D.O.B./Age: Social Sec. No.:

Address:

City: State: Zip:

Phone: Drivers Lic. No.:

Previous Address:

Employment:

Employment Phone:

Address:

Spouse:

Previous Employment:

Last Name: First Name:

D.O.B./Age: Social Sec. No.:

Address:

City: State: Zip:

Phone:

Employment/Other Info.:

Year: Make: Model: Color:

VIN / ID / Serial Number: Plate:

Misc.: Key Codes:

Date of Loan: Loan Account Number:

Payments:$ : Delinquent:#Months (Please Include)

Balance:$: Past Due Date:

INSTRUCTIONS / REMARKS: Insert any information that may be relevant to the
recovery of this assignment.

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:*