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CLIENT INFORMATION

Date
 

Assigned By

Client

Address

Phone Number

City and State

Fax Number

 
DEBTOR INFORMATION

Debtor Name

Social Security No.

Phone Number

Date of Birth
 

Address

City

STATE

ZIP CODE

Employer

Employer Address

Employer Phone

 
COBUYER/SPOUSE INFORMATION

Co Buyer Name

Social Security No.

Phone Number

Date of Birth
 

Address

City

STATE

ZIP CODE

Employer

Employer Address

Employer Phone

 
COLLATERIAL INFORMATION

Account Number

Type of Collateral

Type of Account

Year

Make

Model

VIN Number

License Number

License State

Date of Note

Last Paid
   

Key Codes

High Credit

Amount Past Due

Balance

 
ADDITIONAL INFORMATION

Upon Repossession, the Collateral is to be?

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Email Address

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HOLD HARMLESS AND AUTHORIZATION AGREEMENT
We agree to indemnify and hold American Asset Recovery Company harmless from and against any and all claims, damages, losses and actions resulting from or arising out of American Asset Recovery Company's efforts to collect the above claim, except, however, such as may be caused by or arise out of negligence or unauthorized acts by American Asset Recovery Company, it's employee's or agents. Nothing contained herein shall be construed to authorize the violation of the laws of the State of Ohio.
I am assigning this claim for collection to American Asset Recovery Company.
I am duly authorized by my company to make such an assignment.
I fully understand that by typing my name in the "Assigned By" box above and pressing the "Submit Request" button below, I am digitally signing this authorization.
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Do not put anything in this field.
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