YOUR BUSINESS NAME:______________________________________________________________________ ADDRESS:______________CITY:________ST:______________ZIP:____________________ PHONE:_________FAX:________________________________________________________ CONTACT PERSON____________________________________________________________________ DEBTOR FULL NAME:______________________________________________________________________ ACCOUNT#__________________________________________________________________ ADDRESS__________________CITY___________ST:_______ZIP:_____________________ PHONE:_______SS#_________DOB_____________________________________________ EMPLOYER:____________________________WORK#______________________________ BANK NAME:______________________ACCT#__________________________________________ DEBTOR (2) (SPOUSE) FULL NAME:______________________________________________________________________ ADDRESS____________________________CITY_______________ST_________ZIP______ PHONE:_______________________SS#____________________________DOB__________ EMPLOYER:______________________WK#_______________________________________ MESSAGE#__________________________________________________________________ BANK NAME:_______________________________________ACCT#_________________________ DEBTOR 3 FULL NAME:______________________________________________________________________ ADDRESS:_________________________CITY_________________ST___________ZIP_____ PHONE:___________________SS# :______________________________DOB___________ EMPLOYER____________________________WK#__________________________________ BANK NAME:_________________________________________________ACCT#_______________ DATE OF LAST CHARGE:________DATE OF LAST PAYMENT__________PRINCIPAL AMT:$___________FINANCE/INTEREST$_____________BALANCE$__________________ ____________________________________________________________________________ I hereby transfer, set over and assign unto Bonded Adjustment Company, a corporation, all our right, title and interest in the above claim. Advanced court costs and attorney fees will be paid from the first monies collected. I hereby certify that I have complied with the requirements of Regulation Z of the Truth in Lending Act. SIGNED:_______________________________POSITION:_____________________________ ____________________________________________________________________________ OFFICE USE ONLY_______________________________________________________________________ DATE FILE DATE_______________________________________________________________________ PACKET_____________________________________________________________________ SALESMAN#_________________________________________________________________ ACCOUNT#__________________________________________________________________