R & P Recovery Services

R J Pike & Paul Heck

RT 3 Box 3541
Alton, MO 65606
Phone: 417-778-7312
Fax: 417-778-6550


LEGAL OWNER:________________________________

Description of Property:

Year:________ Make: _______ Model: __________________

Color:__________ Body Style:________ License #: ____________

Serial # (VIN): __________________________________________

SPECIAL DESCRIPTIONS: ______________________________



City:__________________ State: ________________Telephone #:_________________

Age:________ Physical Description: ________________________________________

Employment:______________________ Address:_______________________________

Account Information:

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.

By:________________________ Telephone Number: Day: _____________ Night: ______________