Capitol Recovery Service Assignment Form

<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%> <% If (CStr(Request("MM_insert")) <> "") Then ' send email ' change to address of your own SMTP server strHost = "webmail.webnj.net" Set Mail = Server.CreateObject("Persits.MailSender") ' enter valid SMTP host Mail.Host = strHost Mail.Username = "webinfo@capitolrecoveryservice.com" Mail.Password = "webnj" Mail.AddAddress "webinfo@capitolrecoveryservice.com" Mail.From = Session("webinfo@capitolrecoveryservice.com") Mail.FromName = Request("FromName") ' optional ' message subject Mail.Subject = "Assignment Info sent from www.capitolrecoveryservice.com" ' message body Mail.Body = "1-lienholder = " + Request("1a-lienholder") + chr(10) + _ "1-Address = " + Request("1b-address") + chr(10) + _ "1-city = " + Request("1c-City") + chr(10) + _ "1-state = " + Request("1d-State") + chr(10) + _ "1-zip = " + Request("1e-Zip") + chr(10) + _ "1-phone = " + Request("1f-Phone") + chr(10) + _ "1-extension = " + Request("1g-extension") + chr(10) + _ "1-fax = " + Request("1h-Fax") + chr(10) + _ "1-email = " + Request("1i-Email") + chr(10) + _ "1-Collector = " + Request("1j-collector") + chr(10) + _ "2-debtor = " + Request("2a-debtor") + chr(10) + _ "2-Address = " + Request("2b-address") + chr(10) + _ "2-city = " + Request("2c-City") + chr(10) + _ "2-state = " + Request("2d-State") + chr(10) + _ "2-zip = " + Request("2e-Zip") + chr(10) + _ "2-phone = " + Request("2f-Phone") + chr(10) + _ "2-extension = " + Request("2g-extension") + chr(10) + _ "2-fax = " + Request("2h-Fax") + chr(10) + _ "2-email = " + Request("2i-Email") + chr(10) + _ "2-ssn & birth = " + Request("2j-Social Security Number and Date of Birth") + chr(10) + _ "3-employment = " + Request("3a-employment") + chr(10) + _ "3-Address = " + Request("3b-address") + chr(10) + _ "3-city = " + Request("3c-City") + chr(10) + _ "3-state = " + Request("3d-State") + chr(10) + _ "3-zip = " + Request("3e-Zip") + chr(10) + _ "3-phone = " + Request("3f-Phone") + chr(10) + _ "3-extension = " + Request("3g-extension") + chr(10) + _ "3-fax = " + Request("3h-Fax") + chr(10) + _ "4a-Collateral = " + Request("4a-Collateral Year Make Model") + chr(10) + _ "4b-plate state = " + Request("4b-Plate State Color") + chr(10) + _ "4c-key num = " + Request("4c-Key Numbers") + chr(10) + _ "4d-vin = " + Request("4d-Vehicle Identification Number") + chr(10) + _ "5a-Loan Number = " + Request("5a-Loan Number") + chr(10) + _ "5b-Past Due = " + Request("5b-Past Due Date") + chr(10) + _ "5c-Monthly Pmt = " + Request("5c-Monthly Payment") + chr(10) + _ "5d-Loan Bal = " + Request("5d-Loan Balance") + chr(10) + _ "6a-Assign Type = " + Request("6a-Assignment Type") + chr(10) + _ "7a-Comments = " + Request("7a-Comments") + chr(10) + _ "8a-Auth By = " + Request("8a-Authorized By") + chr(10) + _ "8b-Date = " + Request("8b-Date") + chr(10) strErr = "" bSuccess = False On Error Resume Next ' catch errors Mail.Send ' send message If Err <> 0 Then ' error occurred strErr = Err.Description else bSuccess = True End If Response.Redirect(Request("REDIRECT")) End If %> Capitol Recovery Service Assignment Form

Capitol Recovery Service
Corporate Headquarters
P.O. Box 2206
Ocean N.J. 07712
Phone: 732.919.7873 | Fax: 732.919.7937
Toll Free: 800.676.7352

Lienholder:

Address: ......

City:.............State: Zip:..

Phone: .........Ext: .. Fax:

E-mail:..........

Collector: .....

Debtor:..

Address:..

City: .........State:Zip:.

Phone: ......Ext:..Fax:

E-mail:.......

SS#/DOB:

Employment:

Address: ........

City: ..............State:Zip:..

Phone:............Ext.:..Fax:

Collateral Yr, Make, Model:

Plate, State & Color: ...............

Key Numbers:............... .........

Vehicle Identification Number:.[Be sure to include all 17 numbers]

Loan Number: ..

Past Due Date: .. .

Monthly Payment: Loan Balance:

Assignment Type:

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.

Provide additional information in this space:

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:

Any questions? Please contact us at 800.676.7352
Or you may Fax us at: 732.919.7937
Or you may also contact us via E-mail at:

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