Corporate Headquarters P.O. Box 958 Manchester, Connecticut 06045-0958 Phone: 860.282.0065| Fax: 860.282.0749
Lienholder:
Address: ......
City:.............State:Zip:..
Phone:.......Ext: .. Fax:
E-mail:..........
Collector: .....
Debtor:..
Address:..
City: .........State:Zip:.
Phone: ......Ext:..Fax:
E-mail:.......
SS#/DOB:
CoMaker:..
CoMaker Address:..
Employment:
Address: ........
City: ..........State:Zip:..
Phone:.........Ext.:..Fax:
Collateral Yr, Make, Model:
Plate, State & Color: ...............
Key Numbers:............... .........
Vehicle Identification Number:.[Be sure to include all 17 numbers]
Loan Number: ..
Past Due Date: .. .
Total Amt. Past Due: Date of Last Payment:
Monthly Payment: . .Loan Balance: . . . . . .
Assignment Type: InvoluntaryVoluntary Contact and Collect Condition ReportDMV 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.
Comments:
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:
