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Lienholder Information |
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| Lienholder: |
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E-Mail Address: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
Ext:
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| Fax: |
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Collateral Information
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| Year: |
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VIN Number: |
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| Make: |
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State: |
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| Model: |
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Ignition Key Number: |
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| Color: |
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Trunk Key Number: |
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| Storage Instructions: |
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Debtor Information
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| Debtor Name: |
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Co-maker Name: |
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| Home Address: |
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Home Address: |
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| City |
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City |
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| State |
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State |
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| Zip |
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Zip |
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| Home Phone: |
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Home Phone: |
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| SSN: |
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SSN: |
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| DOB: |
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DOB: |
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| Debtor Employer: |
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Co-maker Employer: |
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| Work Address: |
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Work Address: |
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| City |
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City |
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| State |
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State |
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| Zip |
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Zip |
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| Work Phone: |
Ext:
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Work Phone: |
Ext:
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| Work Fax: |
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Work Fax: |
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Loan Information
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Loan Number:: |
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| Balance Due |
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| Monthly Payment: |
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Past Due Date:
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| Past Due Amount: |
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| Assignment Type: |
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| Does this assignment require a price quote in
advance? :Yes No |
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| Special Instructions: |
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This is your
authorization to act as our agent to collect or reposes the above collateral. We
agree to indemnify, and hold 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 reposes 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. |
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| Assigned by: |
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Date: |
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