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On-line repossession assignment form

DEBTOR INFORMATION

CITY, STATE

         ZIP

LIEN HOLDER INFORMATION

LIEN HOLDER

COLLECTOR

ADDRESS

CITY, STATE

ZIP

PHONE (EXT.)

FAX

E-MAIL

DEBTOR

CO-BUYER

ADDRESS

PHONE

PHONE

ADDRESS

CITY, STATE

         ZIP

D.O.B.

S.S.#

D.O.B.

S.S.#

EMPLOYER

COMPANY

ADDRESS

CITY, STATE

PHONE (EXT.)

COLLATERAL TO RECOVER

YEAR

VIN#

LOAN #

PAST DUE

ZIP

FAX

PLATE

ACCOUNT #

MAKE

MODEL

COLOR

STATE

KEY CODE

TYPE

As lienholder and legal owner of the above described collateral, the above singed authority hereby declares that the debtors contract of sale or security agreement covering above named collateral is in default.  We authorize THE FINAL NOTICE AGENCY, INC., or their designated licensed agent to act on our behalf and repossess said collateral on sight.  We agree to indemnify and hold harmless THE FINAL NOTICE AGENCY, INC., and their licensed agents from and against any claims, damages, losses or legal action resulting from or arising out of their efforts to repossess the above named collateral. All federal and state laws pertaining to repossessions are to be complied with.

AUTHORIZED BY

DATE