Submit your Online Assignment Form here:

To send additional documents, complete the online form
and then click here to add attachments.


*Lienholder:
Address:
City:
State:    Zip:
Phone:    Extension:
Fax: 
E-mail:
Collector: 

Debtor:
Address: 
City:
 State:     Zip:
Phone:
Fax:
E-mail:
SSN and Date of Birth:

Debtor's POE:
Address: 
City:
State:    Zip:
Phone:    Extension:

Co-Maker:
Address: 
City:
 State:     Zip:
Phone:
Fax:
E-mail:
SSN and Date of Birth:

Co-Maker's POE:
Address: 
City:
State:    Zip:
Phone:    Extension:

Collateral Year, Make & Model:
Plate, State & Color: 
Key Numbers:
Vehicle Identification Number: 

Loan #:
Past Due Date: 
Monthly Payment:
Loan Balance: 
Assignment Type: 


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.

Please fax a copy of the Vehicle Title with Lienholder, and signed Hold Harmless agreement.
Fax: (319) 346-9797    Telephone: (319) 404-9040 or (319) 404-5519

Authorized by:
Date:
*All fields marked with an asterisk are required

Corporate Office | 33617 6th Street | Parkersburg, IA 50665

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