Statewide Recovery Services
14340 Arrow Highway
Baldwin Park, CA 91706
Phone: (626) 442-4446 | Fax: (626) 329-0518

Lienholder:
Address
City:
State:  Zip:
Phone:  Ext:
Fax:
E-mail:
Collector:
Debtor:
Address:
City:
State:  Zip:
Phone:  Ext:
Fax:
E-mail:
SS#/DOB:
Employment:
Address:
City:
State:  Zip:
Phone:  Ext:
Fax:
Collateral:
(Yr, Make, Model)
Plate, State & Color:
Key Numbers:
VIN: [Be sure to include all 17 numbers]
Loan Number:
Past Due Date:
Monthly Payment:
Loan Balance:
Assignment Type:

Note: Should you have any information regarding family members, relatives of the debtor, or any unique or defining information that would be helpful in aiding us in the recovery of your vehicle, please enter that information in the "Instructions" space below.

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.
Authorized by:
Date:
Please type in the box the numbers and/or letters you see.
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Any Questions? Please feel free to contact us at (626) 442-4446
Or you may contact us via E-mail at: