Lake City Corporate Office and Gainesville Branch | Phone: 800.533.3117 or 386.752.2850 | Fax: 386.755.0107
Lienholder:
Address:
City: State: Zip:
Phone: Extension: Fax:
E-mail:
Collector:
Loan Number:
Debtor Last Name:First:Middle:
Phone: Fax:
Date of Birth:Social Security Number:
Cosigner Name:
Employment:
Co-Maker Last Name:First:Middle:
Co-Maker Employment:
Collateral Year & Make: Model:
Vehicle Identification Number(VIN):
Color:Plate:State:
Ignition Key Number: Door Key Number:
Past Due Date: (dd/mm/yy)
Monthly Payment: ($xxx.xx)
Loan Balance: ($xx,xxx.xx)
Assignment Type: Involuntary Voluntary Contact and Collect Condition Report Skip TracingField Visit
Note: Should you have any information regarding the Cosigner, 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 "Instructions" space 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:
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