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Assignment Form
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Assignment type
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Involuntary Repossession
Voluntary Repossession
Impound
Pictures and Condition Report
Field Call
LIENHOLDER INFORMATION
*
Lienholder
*
Contact
Email
*
Street
*
City
*
State
*
Phone
Fax
*
Zip Code
LOAN INFORMATION
*
Account Number
Past Due Date
PAYMENT INFORMATION
Payment
Past Due
Balance
PRIMARY BUYER
*
First Name
*
Last Name
DL Number
*
Street
*
City
*
State
Primary Phone
Secondary Phone
*
Zip Code
SECONDARY BUYER
First Name
Last Name
DL Number
Street
City
State
Primary Phone
Secondary Phone
Zip Code
PRIMARY BUYER POE
Employer
Employer Phone
Employer Address
Employer City
COLLATERAL INFORMATION
*
Year
*
Model
*
Make
License Plate Number
State Issued
*
Complete VIN
ADDITIONAL INFORMATION
Terms and Conditions
You hereby authorize Centroplex Auto Recovery, Inc. to act as your agent to collect or repossess the collateral referenced in this Assignment Form. You 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 our efforts to collect and or repossess assignments except in the event of negligence on the part of Centroplex Auto Recovery, Inc. Our firm does not work on a contingency basis unless agreed upon prior to working this assignment.
*
I Agree to the Terms and Conditions
I Agree
AUTHORIZING AGENT NAME
*
Agent Name
*
Agent Phone
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