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Prairie Land Services, Inc - Your Professional Recovery Specialists

Fill Out This Form, then Press "Submit"
888.404.REPO   316.219.2929   f-219-9090
*** note: DO NOT hit enter until you are ready to send the form; use TAB***

Legal or Forwarding Agent/Owner Information: * = Required
Return Email: *
Legal Owner: *
Owner's Address: *
Assigned By: * Date: *
Phone: * Extension:
Fax: Watts or 800 #:
Debtor Information: * = Required
Customers Name: *
Home Address: City, State, Zip:
Employer:
Work Address: City, State, Zip:
Home Phone: Work Phone:
DOB: SS #: *
Spouse's Name:
Spouse's DOB: Spouse's SS#:
Collateral Property Information: * = Required
Year: * Make: *
Model: * Color:
License #: State:
Ignition Key #: Trunk Key #
VIN #: *
Loan Information: * = Required
Loan Number: Balance: *
Past Due Date: Monthly Payment:
Past Due Amount: *
Assignment Type:


The issue of this assignment requires a price quote in advance: * Yes No
Please state when the Right to Cure was sent and any other Special Instructions:
In the state of Kansas you MUST have a RTC sent before recovery can start!
Storage Instructions:
This is authorization to act as our agent to collect or repossess the above 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, 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.