Pentafix, Inc.
Northern Recovery & Transport
P.O. Box 2066
Flagstaff, AZ 86003
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Lienholder:
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Address
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Collector:
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Debtor:
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Address:
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SS#:
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DOB:
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Employment:
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Collateral:
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Plate, State & Color:
Key Codes:
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VIN:
[Include all 17 numbers]
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Loan Account #:
Past Due Date:
Monthly Payment:
Loan Balance:
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Assignment Type:
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Voluntary
Contact and Collect
Condition Report
DMV
MVR
This is your authorization to act as our agent to collect or repossess the above collateral. We agree to indemnify and hold you 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.
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Authorized by:
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Date:
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