MCX Assignments
MCX Assignments
Submit your assignment using our online form here:
* Required Fields
*
Lienholder:
*
Address
*
City:
*
State:
*
Zip:
*
Phone:
Ext:
Fax:
*
E-mail:
*
Collector:
*
Debtor:
*
Address:
*
City:
*
State:
*
Zip:
Phone:
E-mail:
*
SS#:
*
DOB:
*
Employment:
Address:
City:
State:
Zip:
Phone:
Ext:
Fax:
*
Collateral:
(Yr, Make, Model)
Plate, State & Color:
Key Codes:
*
VIN:
[Include all 17 numbers]
*
Loan Account #:
Past Due Date:
Monthly Payment:
Loan Balance:
*
Assignment Type:
Involuntary
Voluntary
Contact and Collect
Condition Report
DMV
MVR
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. ~~~~~~~~ PLEASE PROVIDE ADDITIONAL INFORMATION IN THIS SPACE: ~~~~~~~~
*
Authorized by:
*
Date:
Please type in the box the numbers and/or letters you see.
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Corporate Office | P.O. Box 61924 | Lafayette, Louisiana 70596
Toll-Free: 888-517-8914 or 866-406-0833 | Fax: 337-993-3032
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