Repossession Assignment Request Form

Leinholders Information
Firm Name:
Agent Name:
Address:
City:
State:
Zip:
Phone:
Extension:
Fax:
eMail:

Debtors Information:
Account Number:
Debtor's Full Name:
Address:
City:
State:
Zip:
Phone:
Extension:
Fax:
E-mail:
Social Security Number:
Date of Birth:
Drivers License:

Employment:
Address:
City:
State:
Zip:
Phone:
Extension:
Fax:
Collateral Information
VIN
Collateral Year:
Collateral Make:
Collateral Model:
Collateral Color:
Plate / State
Key Numbers/ Code:
Ignition Numbers / Code:
Trunk Numbers / Code:
Contract Information
Loan Number:
Original Contract Date:
Past Due Date:
Past Due Amount:
Monthly Payment:
Loan Balance:
Last Payment Date:
Assignment Type:
Additional Information
Please enter any additional information related to this debtor, including: family members, relatives, friends or any other information that would be helpful in speeding the recovery of your collateral. Please provide any additional information here:
This is your authorization to act as our agent to collect or repossess the above collateral, which is covered by a defaulted contract. We agree to indemnify and save you harmless from and against any and all claims, including court costs, reasonable attorney fees and other expenses of litigation, except for unauthorized acts of your firm. This immdemnification is granted as consideration for you acting as our agent. It is agreed that this contract is executed within your state and that the laws of your state and shall be applicable. When there are two states involved, the laws of both staes may be applicable.
Repossession Order Authorized by: Authorization Date:

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Repossession Assignment Request Form

Leinholders Information

Debtors Information:

Collateral Information

Contract Information

Additional Information