Lien Holder

Address
City State Zip  
Collector After Hours
Phone # After Hours
Fax # Email

Debtor

Address  
City State Zip  
Phone 1 Phone 2  
SSN DOB  

Employment
Address  
City State Zip  
Phone 1 Phone 2  
Supervisor

Co-X/Spouse

Address
City State Zip  
Phone 1 Phone 2
SSN DOB

Employment
Address
City State Zip
Phone 1 Phone 2
Supervisor

Collateral

Year Make Model  
State Plate Color
Door key code Ignition key code Keys? Yes No
VIN Number

Loan

Loan number
Past Due Date Past Due Amount $  
Monthly Payment $ Loan Balance $
Assignment Type

University Parking Enforcement to provide 10 day covered storage?

Yes No

Additional Information

Hold Harmless Agreement

This shall serve as authority for University Parking Enforcement to act as our agents in the above described matter, following the instructions outlined. We agree to indemnify and save University Parking Enforcement 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 cause 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.

I have read and agree to the "Hold Harmless Agreement"

 
Authorized Lien Holder Representative   Assignment Date