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Assignor Information:
Assigned By: *		Company:
Phone: *		Extension:
Fax:		Toll Free #:
Assignor's Email: *		Verify Email: *
Assignment Date:
Assignment Type: *	Example: Involuntary, Voluntary, Door Knock, Skip Locate, etc.

Lien Holder / Legal Owner Information:
Lien Holder / Legal Owner: *
Owner's Address
City:
State:
Zip:

Debtor Information:
Debtor's Name: *
Home Address: *
City: *
State: *
Zip: *
Employer:
Work Address:
City:
State:
Zip:
Home Phone:		Work Phone:
DOB:		SS #:
Spouse's Name:
Spouse's DOB:		Spouse's SS #:

Co-Maker Information:
Co-Maker's Name:
Home Address:
City:
State:
Zip:
Employer:
Work Address:
City:
State:
Zip:
Home Phone:		Work Phone:
DOB:		SS #:
Spouse's Name:
Spouse's DOB:		Spouse's SS #:

Collateral Property Information:
Year: *		Make: *
Model: *		Color:
License #:		State:
Ignition Key #:		Trunk Key #:
VIN #: *

Loan Information:
Loan Number: *		Balance:
Past Due Date:		Monthly Payment:
Past Due Amount:

This is authorization to act as our agent to collect or repossess the above collateral. We agree to indemnify, and hold Midwest Recovery & Adjustment, Inc. 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.

This assignment is being forwarded to you through the AFA's automated assignment system on the internet at Web Site: http://www.alliedfinanceadjusters.com/

To Submit your work order, check the box below and click on the 'send assignment' button.