Fill out the form below to submit your request to Mid-State Liquidators.

We will contact you with in 24 hours if there are any questions.

Lien holder:  
Address:  
City: State: Zip:
Phone: Ext: Fax:
Email:  
Collector:  

Borrower:  
Address:  
City: State: Zip:
Phone: Ext: Fax:
Email:  
Social Security Number:  
DOB:  

Employer:  
Address:  
City: State: Zip:
Phone: Ext: Fax:

Co-Borrower:  
Address:  
City: State: Zip:
Phone: Ext: Fax:
Email:  
Social Security Number:  
DOB:  

Employer:  
Address:  
City: State: Zip:
Phone: Ext: Fax:

Collateral Year: Make: Model:
Plate State & Color:  
Key Numbers:  
Vehicle Identification Numbers:

Loan #  
Past Due Amount:  
Monthly Payment: Loan Balance:
Assignment Type:  

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: