Your Name:
Company:
Address:
City/State/Zip:
Telephone:
Fax:
Email Address:
Debtor Name:
Debtor Address
Social Security No:
Date of Birth:
Employer:
Employers’ Address
Year/Make/Model
Plate/State/Color
Key Numbers
VIN Number
Loan Number
Date Past Due:
Monthly Payment
Assignment Type:
Additional Info you may have on debtor
Balance Due
This is your authorization to act as our agent to collect or reposess the above collateral. We agree to indemnify and hold Nu-Era Services Inc., harmless from and against any and all claims, damages, losses, and actions including reasonable legal 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, it’s officers, employess or it’s agents
Authorized by:
Date:
