Lienholder:

Address:

City: State: Zip:

Phone: Extension: Fax:

E-mail:

Collector:



Debtor:

Address:

City: State: Zip:

Phone: Extension: Fax:

E-mail:

Social Security Number and Date of Birth:



Employment:

Address:

City: State: Zip:

Phone: Extension: Fax:



Collateral Year, Make & Model:

Plate, State & Color:

Key Numbers:

Vehicle Identification Number:



Loan #:

Past Due Date:

Monthly Payment: Loan Balance:

Select your assignment type: (mark all boxes that apply) Involuntary RepoVoluntary Repo Skip TraceInvestigateField ContactCondition Report & PhotosMVD Vehicle RecordMVD Dr. Lic RecordTitle ServicesRemarketing & Sell



This is your authorization to act as our independent agent to (mark all boxes that apply) Repossess Skip trace Investigate Field Call

Authorization & Hold Harmless: This is your authorization to act as our independent agent to do the action checked above to the following described collateral and or debtor(s) for which we hold a valid security interest in the above assigned vehicle. We agree to indemnify and save Autotrak & Recovery harmless from and against any and all claims, damages, losses, and actions resulting from or arising out of Autotrak & Recovery efforts to repossess, skip trace, investigate, and or field call the collateral and or the account including unauthorized acts committed by us based on inaccurate information provided to Autotrak & Recovery except for unlawful acts committed by Autotrak & Recovery. We also agree to remit payment to Autotrak & Recovery for services rendered upon receipt of invoice(s) and we understand Autotrak & Recovery does not work on a contingent basis and we acknowledge results are not guaranteed. We will cease collection efforts on our part while Autotrak & Recovery is working this account and we will notify you of any information we may receive or obtain regarding this account.

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 "Comments" space below.

Comments:

Authorized by:Date:

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