Hold Harmless

Vehicle Release

Client Login

Financial Adjusters, Inc.
P.O. Box 266
Whitehall, PA 18052

Toll Free: 800.368.4200
Local: 610.820.8311
Fax: 610.820.0313

Online Assignment Form

* Required Fields
*Lienholder:
*Address:
*City:
*State:	*Zip:
*Phone:	Ext:
Fax:
*E-mail:
*Collector:
*Debtor:
*Address:
*City:
*State:	* Zip:
Phone:
E-mail:
*SS#:
*DOB:
*Employment:
Address:
City:
State:	Zip:
Phone:	Ext:
Fax:
Co-Debtor:
Address:
City:
State:	Zip:
Phone:
E-mail:
Co-Debtor SS#:
Co-Debtor DOB:
Co-Debtor Employment:
Address:
City:
State:	Zip:
Phone:	Ext:
Fax:
*Collateral (Year, Make, Model):
Plate, State & Color:
Key Codes:
* VIN:
*Loan Acct #:
Past Due Date:
Mo Paymt:
Loan Balance:
*Assignment Type:	Involuntary Voluntary Contact and Collect Condition Report DMV MVR
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. PLEASE PROVIDE ADDITIONAL INFORMATION IN THIS SPACE:
*Authorized by:
*Date:
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