Assignment Form

Use this form to request and authorize Tri-County Adjustment Bureau to collect collateral from a debtor who has failed to make payments according to the loan contract. You will be contacted before any action is taken.

Note: Fields marked with "*" are required. Please enter as much valid information as possible.

*Lienholder:
Address:
City:	State: Zip:
*Phone:	Ext:
Fax:
Attn: (collector)

*Debtor:
Address:
City:	State: Zip:
Phone:
SSN:	Date of Birth:

Debtor Employer:
Address:
City:	State: Zip:
Phone:

*Collateral Year, Make, Model, & Color:
VIN #:
License Plate # & State:
Key Numbers:

Loan #:
Oldest Payment Due Date:
Normal Monthly Payment:	Loan Balance:

Note: Please enter any information regarding family members or relatives of the debtor or other information that would help us in the recovery of your collateral:

This assignment form authorizes Tri-County Adjustment Bureau (TCAB) to act as our agent to collect (repossess) the above collateral. We agree to indemnify and hold TCAB harmless from and against any and all claims, damages, losses, and actions including reasonable attorney fees, resulting from and arising out of TCAB's 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 TCAB, its officers, its employees, or its agents.
*Authorized by:
Date:
*Email Address: