SSN:

                            DOB:

                    Co Maker: 

                        Address:

                             City:

                           State:     Zip:

                          Phone:    Ext:

                             SSN:

                            DOB:

________________________________________________________________________________________________

                    Employment:

                        Address:

                              City:

                            State:    Zip:

                           Phone:   Ext:

                               Fax:

              Co Maker POE:

                        Address:

                             City:

                           State:     Zip:

                          Phone:   Ext:

                              Fax:

________________________________________________________________________________________________

Collateral (Yr, Make, Model):

                  Plate Number:

                             State:

                             Color:

                               VIN:

                                           Be sure to include all 17 numbers.

________________________________________________________________________________________________

                   Loan Number:

                Past Due Date:

          Monthly Payments:

                 Loan Balance:

           Assignment Type:  Involuntary

                                      Voluntary

                                      Contact and Collect

                                      Skip Tracing

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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 collateral, please enter it in the box below.

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: