DATE: ASSIGMENT TYPE: Choose an item.

CLIENT ACCOUNT #: CLIENT /

LEGAL OWNER:

Address:
City: State:
Phone: Fax:
Assigned BY:

DEBTOR: CO-SIGNER:

D of B: D of B:
SS#: SS#:
Address: Address:
City: City:
State: State:
Phone: Phone:
Cell: Cell:
POE INFO: POE INFO:

ADDITIONAL INFO:

VEHICLE INFORMATION

YEAR: MAKE: MODEL:

VIN:
TAG: COLOR:

PAYMENT INFORMATION

Monthly PMT: DEL Since: ACCT BAL:

This document serves as authorization to repossess, impound and transport the collateral which is covered by a defaulted
installment contract or lease agreement between lien holder and debtor/lessee. Reliable Recovery Services LLC is our
exclusive agent for repossessing the collateral effective immediately. This means that any agent we have previously engaged is no
longer authorized to repossess this collateral and have been properly notified. We agree to indemnify, defend, and hold
Reliable Recovery Services LLC, harmless from and against any and all claims, damages, Losses, or actions resulting from efforts to
collect the collateral, except however, such as may be caused by or arise out of negligence or unauthorized acts of Reliable
Recovery Services LLC, its officers, or employees as such agents. We understand that Reliable Recovery Services LLC is bound by
and subject to the recovery laws of The State of Texas. We also agree that if the debtor or his agent(s) should surrender the
collateral to anyone else during the term of this agreement it will be deemed to have been voluntarily repossessed by Reliable
Recovery Services LLC; anyone else is understood to mean but is not limited to, body shops, police impound lots, other
repossession company, or to any facility under our direct or indirect control.
Authorized By (Print Please)

Authorized Signature & Date:

RELIABLE RECOVERY SERVICES LLC

Mailing Address: 251 SW Wilshire Blvd #1 24-614. Burleson, TX 76028
(o) 817.727.8266 (f) 817.727.8277
Physical Address: 2557 S Riverside Dr. Fort Worth, TX 761 04