RT 3 Box 3541
Alton, MO 65606
Description of Property:
Year:________ Make: _______ Model: __________________
Color:__________ Body Style:________ License #: ____________
Serial # (VIN): __________________________________________
SPECIAL DESCRIPTIONS: ______________________________
City:__________________ State: ________________Telephone #:_________________
Age:________ Physical Description: ________________________________________
Amount Past due:____________ Last Payment Date: ______________ Payoff Amount: ____________
This shall serve as authority for your firm to act as our agents in the above described matter, following the instructions outlined. We agree to indemnify and save you harmless from and against all claims, damages, losses and actions resulting from or arising out of your efforts to the above claim, except, however, such as may be caused by or arise out of the negligence or unauthorized acts of your agency, its offices, employees or agents, or the officers or employees of such agents. We understand that this assignment will be acknowledged, and that interim and final reporting will be made, with all billing in detail. Please Print and fax to our office at 417-778-6550.
Please Print and fax to our office at 417-778-6550.
By:________________________ Telephone Number: Day: _____________ Night: ______________