US Recovery Services

PO Box 6015
Bismarck, ND 58506-6015
701.255.0533 | 1.800.249.7313 | Fax: 866.409.5770

Date: Voluntary Involuntary
Name: SS #:
Home Phone: Work Phone:
Employer: Employer Add:
Year: Make: Model:
License Plate: Color: VIN #:
Co-Buyer Info:
Payment: Past Due: Unpaid Balance:
Special Instructions:

This account has no bankruptcy proceedings and this is your authorization to act as our agent to collect or repossess the above mentioned collateral.

We agree to indemnify and hold 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 such as may be caused by or arise out of negligence or unauthorized act on the party of you, your company, its officers, employees or its agents.

Authorized Officer:
Telephone: Fax: