U.S. Recovery Service, Inc.

      Corporate Headquarters
      13757 Seminole Dr.
      Chino, CA 91710-5515
      Phone: 909.364.8511 | Fax: 909.364.8611
      Toll Free: 800.356.7376


            Lienholder: 

            Address: ......

            City:.............State: Zip:..

            Phone: .........Ext: .. Fax: 

            E-mail:..........

            Collector: .....

            Debtor:.. 

            Address:..

            City: .........State:Zip:.

            Phone: ......Ext:..Fax: 

            E-mail:.......

            Employment:

            Address: ........

            City: ..............State:Zip:..

            Phone:............Ext.:..Fax: 

            Collateral Yr, Make, Model:

            Plate, State & Color: ...............

            Key Numbers:............... .........

            Vehicle Identification Number:.[Be sure to include all 17 numbers]

            Loan Number: ..

            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.

            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.

      Authorized by:Date:

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      Any questions? Please contact us at 800.356.7376
      Or you may also contact us via E-mail at:


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