Assignment Form

*Lienholder:

Address:

City:

State:

Zip:

Phone:

Ext:

Fax:

E-mail:

Collector:

Debtor:

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

SSN and Date of Birth:

Debtor's POE:

Address:

City:

State:

Zip:

Phone:

Ext:

Co-Maker:

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

SSN and Date of Birth:

Co-Maker's POE:

Address:

City:

State:

Zip:

Phone:

Ext:

Collateral Year, Make & Model:

Plate, State & Color:

Key Numbers:

Vehicle Identification Number:

Loan #:

Past Due Date:

Monthly Payment:

Loan Balance:

Assignment Type:

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.

Please provide information and instructions in this space:

This is your authorization to process for collection, location, or repossession of the above described assignment. We agree to indemnify and save you harmless from and against any claims, damage, losses, and action resulting from or arising out of your efforts to collect, locate or repossess the above claim, except, however such as may because or arises out of negligence or unauthorized acts of your company, its officers, employees, or the officers or employees of such agents.

Authorized by:
Date:
*All fields marked with an asterisk are required