Name (on Collateral Title)
Year, Make, and Model (of Collateral)
Address (where Collateral is located)
State / Province / Region
Postal / Zip Code
Surrender Efforts to Date (check all that apply)
I have called the Lien-holder re: Collateral
I have Written the Lien-holder re: Collateral
Lien-holder has called me to pick-up Collateral
Other efforts (e.g., missed appointment, etc.)
There have been no surrender efforts to date
Other (explain below)
Please explain the efforts, if any, to surrender the Collateral.
Please enter the approx. date of the last payment on Collateral.
Has your Bankruptcy already been filed?
Name of your Bankruptcy Attorney/Firm?
Agree to the Terms and Conditions
I agree to the Terms and Conditions
Please check the box if you have read and agree to all of the
terms and conditions