Online Assignment

Assignment Form

[Fields with an * Are required]

Lienholder
*Lienholder:
*Address:
*City:	State: Zip Code:
*Phone:	Ext: Fax:
E-mail:
*Collector:
Debtor
*Debtor Name:
*Address:
*City:	State: Zip Code:
*Phone:	Ext: Fax:
E-mail:
*Social Security Number:
*Date of Birth:
Debtor Employment Info
Employment:
Address:
City:	State: Zip Code:
Phone:	Ext: Fax:
Collateral Info
Year: Make: Model:
License Plate: State: Color:
Key Numbers:
Ign: Door: Vats/Pats:
VIN: [Please remember all vehicles built after 1981 have 17 digits]
Loan Info
*Loan #:
*Last Paid:
*Next Due:
*Monthly Payment:
*Loan Balance:
*Assignment Type:
SPECIAL INSTRUCTIONS or ADDITIONAL INFORMATION
By submitting this form and data (I/We) (Am/Are) authorizing you to act as (My/Our) agent to collect or repossess the above collateral. (I/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: Title: *Date: