Liberty Lender Services
1640 Marquette St Bay City, MI 48706
Office – 989-667-2001 Fax- 989-667-2012
Date:___________________ Creditor/Lienholder:_____________________________
Address: _______________________________
_______________________________
Phone #: ____________ Fax #:_____________
Assigned By: _______________________________
Repossession Type [ ] Voluntary [ ] Involuntary
Borrower Name: ________________________ S.S.#: ______________________________
Spouse Name:___________________________
Address:_____________________________________________________________________
Phone #:___________________________ Business Phone #:_____________________
D.L. #: _______________________________ D.L. State: _______ DOB: ___________
Co-Borrower Name: _______________________ S.S.#: _____________________________
Address:_____________________________________________________________________
Phone #:___________________________ Business Phone #:_____________________
D.L. #: _______________________________ D.L. State: _______ DOB: _____________
Collateral
Year/Make/Model:________________________ Body:_______________________________
VIN: __________________________________ Color:______________________________
Plate #:_______________ State:_________ Key Codes:_______________
Other Comments/Special Notes:______________________________________________________
______________________________________________________________________________
Balance Due:$__________ Amount Due:$__________ Past Due Date:___________
Monthly Payment:$_________
By signing this, you authorize Liberty Lenders to act as your agents to repossess the collateral listed above. This will certify that we have immediate possession of this collateral, agree to indemnify and to keep you harmless from and against any claims, except unlawful acts from your firm. Nothing contained hereon should authorize the violation of your state’s law.
Signature:________________________________
Printed Name:_____________________________