Your Information		* - indicates required field
	Your Name:*
	Company:*
	Address:*
	City, State Zip:*
	Email:*
	Telephone:*
	Fax:
Debtor Information
	Debtor Name*
	Address:
	City, State Zip:
	Phone:
	Email:
	SSN:
	DOB:
Debtor Employer
	Employer:
	Employer's Address:
	City, ST Zip:
	Phone:
	Fax:
Collateral
	Year/Make/Model:
	Plate/State/Color:
	Key Codes:
	VIN:
	Loan Numbers:
	Date Past Due:
	Monthly Payment:
	Balance Due:
	Assignment Type:	Involuntary Voluntary Field Hit CR / Pictures
Additional Information
	Additional Info you may have on Debtor:
This is your authorization to act as our agent to collect or repossess the above collateral.  We agree to indemnify and hold American Powersport Recovery, 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, its officers, employees or it’s agents
	Authorized By:
	Date: