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Lienholder:
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Address:
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City:
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State:
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Zip Code:
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Phone
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Ext:
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Fax:
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New Client:
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Yes
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No
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Email:
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Collector:
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************************************************************************************
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Debtor:
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Address:
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City
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State
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Zip Code
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Home Phone:
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Cell Phone:
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SS#
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DOB:
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Debtor Poe:
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Address:
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City:
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State:
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Zip Code:
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Poe Phone:
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Ext:
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**************************************************************************************
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Comaker:
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Address:
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City:
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State:
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Zip Code:
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Home Phone:
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Cell Phone:
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SS#:
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DOB:
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Comaker Poe:
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Address:
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City:
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Zip Code:
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State:
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Poe Phone:
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Ext:
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*****************************************************************************************
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Collateral Year, Make & Model
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VIN:
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Include all17 numbers
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Tag:
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Key Code:
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Color:
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******************************************************************************************
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Account Number:
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Past Due Date:
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Monthly Payment:
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Loan Balance:
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Date of Loan:
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Assignment Type:
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******************************************************************************************
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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 space provided below.
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This is your authorization for National Vehicle Recovery of Georgia, Inc., 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.
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Authorized by:
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Title:
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Date:
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This will acknowledge, with thanks, the above assignment. We will bring this matter to a prompt conclusion and keep your firm fully informed as to the status of this account.
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