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PHONE: (313) 538-2100 -- FAX: (313) 538-2904

REPOSSESSION ORDER FORM

Client: Order Date:

Address: By:Ext.:

City: State: Zip:Phone:

Legal Owner: Fax:

E-mail:

DEBTOR INFORMATION

Last Name:First Name:

D.O.B./Age: Social Sec. No:

Address:

City: State: Zip:Phone:

Previous Address:

Employment: Phone:

Address: Spouse:

Prev. Employment: Driv.Lic. No.:

CO-MAKER INFORMATION [If Applicable]

Last Name: First Name:

D.O.B./Age: Social Sec.No:

Address:

City: State: Zip:Phone:

Employment/Other Info.:

VEHICLE INFORMATION

Year Make Model Color

Serial Number

DealerKey Number: Plate:

LOAN INFORMATION

Date of Loan: Loan Account Number:

Payments:$ :Delinquent:Months (Please Provide)

Balance:$: Past Due Date:

REFERENCES/REMARKS:

If you have information on the debtors family members,

relatives of the debtor, or any other information

that would be helpful to us in the recovery of your vehicle,

please enter that information in the "Instructions" space below.

Thankyou.

Authorized by:Date: