FIRST NATIONAL REPOSSESSION, INC.
Box 231 Albertville-Minneapolis-St. Paul Minnesota USA 55301
Phone: (763) 241-5212 Fax: (763) 241-5217
Toll Free: (888) USA-REPO Toll Free: (888) USA-REPO
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LIENHOLDER:__________________________ PHONE: #___________________________
ADDRESS :__________________________ FAX : #___________________________
__________________________ CONTACT:___________________________
AFTER HOURS PHONE:#__________________ AFTER HOURS CONTACT:_______________
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Debtor:____________________________ SS#________________ DL#/DOB__________
CO-X/Spouse:_______________________ SS#________________ DL#/DOB__________
_________________________________________________________(____)___________
Last Known Address Phone
_________________________________________________________(____)___________
Last Known Employment Address Phone
Collateral(year,make,model,etc.):_________________________________________
Color:_________ Key Codes: Ignition_______ door_______ Have Keys? yes no
VIN# __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __________ _____
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Plate # State
Last pay___/___/___ Payment Amount____________ Past Due Amount____________
Pay Off Balance________ Date Pay Off Calculated___/___/___ Per Diem_______
Relatives or additional information:______________________________________
__________________________________________________________________________
Special Instructions:_____________________________________________________
__________________________________________________________________________
HOLD HARMLESS
This shall serve as authority for your firm to act as our agents in the
above described matter, following the instructions outlined. We agree to
indemnify and save you harmless from and against all claims, damages,
losses and actions resulting from or arising out of your efforts to the
above claim, except, however, such as may be caused by or arise out of
the negligence or unauthorized acts of your agency, its offices,
employees or agents, or the officers or employees of such agents. We
understand that this assignment will be acknowledged, and that interim
and final reporting will be made, with all billing in detail.
Sincerely,
____________________________________ _______________ ___________________
Authorized Lienholder Representative assignment date your account number