Request for Repossession

Is the collateral being surrendered voluntarily? *	Yes No
Client/Legal Request Submitted by: *
Company *
Address
City
State
Zip
Contact Person *
Contact Phone *
Contact Fax
Contact Email *
Customer Information: Account Number
Full Name *
Phone *
Birthdate
SSN *
Address *
City *
State *
Zip *
Employer
Employer Address
Employer City
Employer State
Employer Zip
Spouse Full Name
Spouse Phone
Spouse Birthdate
Spouse SSN
Spouse Address
Spouse City
Spouse State
Spouse Zip
Collateral Address
Collateral Type (Car, Truck, Heavy Equipment, ATV, Aircraft etc.)
Year *
Make *
Model *
License Plate
State
VIN *
Comments/Questions: