How Adjustment Service Inc.
12816 NE 21st PL.
BELLEVUE, WA 98005
Phone: 425-885-3700
Fax: 425-885-3733
Date
Account Number
Assignment Type
Client/Lien Holder Information
Address
City
State
Zip
Phone
Fax
Assigned By
Extension
Debtor Information
Address
City
State
Zip
Phone
Cell/Pager
Employer
Employer’s Phone
Employer’s Address
Employer’s City
Employer’s State
Employer’s Zip
Additional Information
Vehicle Information
Year
Make
Model
VIN Number
Color
Key Code #1
Key Code #2
Payment Information
Monthly Payment
Delinquent Since Date
Balance on Account
This is your authorization to process for collection or repossession of the above described assignment. We agree to indemnify and hold you harmless from and against any and all claims, damage, losses and action resulting from or arising out of our efforts to collect or repossess the above claim, except, however, such as may be caused or arisen out of negligence or unauthorized acts of your company, it’s officers, employees, or the officers or employees of such agents.