Lienholder: Loan/Lease Account #:
Address: Loan/Lease Balance:
City: Monthly Payment:
State    ZIP: Late Fees:
Phone: Past Due Date:
Fax: Past Due Balance:
E-mail: Assignment Type:

Debtor Name: Employment:
Address: Address:
City: City:
State    ZIP: State    ZIP:
Phone: Work Phone:
E-Mail: Work Fax:
Date of Birth: Work E-Mail:

Collateral Make: Model:
Year: Color:

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 "Instructions" space below.
This is your authorization to repossess, impound and transport across state lines the above-described collateral which is covered by a defaulted installment. We name Capitol Recovery & Investigations as our exclusive agents for repossessing the above described collateral. This means that any agent we have previously engaged is no longer authorized to repossess this collateral unless they are subsequently authorized to do so by Capitol Recovery & Investigations. We agree to indemnify, defend, and save you harmless from and against any and all claims, losses and actions, except for your unauthorized efforts and/or actions which may be acts of our company, its officers, employees or agents. Should the collateral be found with repair charges and or storage charges incurred in such an amount that they exceed our estimate of the value of the collateral, I also understand this is a contingent repossession and I will not be charged unless the collateral is repossessed We will pay a negotiable closeout fee if we cancel this repossession assignment prior to the 30 days. We also agree that if the debtor or his agent(s) should surrender the collateral to anyone else during the term of this agreement it will be deemed to have been repossessed by Capitol Recovery & Investigations. Anyone else is understood to mean but is not limited to, body shops, police impound lots, other repossessors or to any facility under our direct or indirect control. Your special immediate efforts will be appreciated.

Authorized by: Date:

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