COMPLAINT DEALER ASSIGNMENT

Client*

Full legal business name as it appears on Secretary of State filings

Address Line 1

Address Line 2

Email of Client Contact*

Multiple Defendants* YesNo

First Name MI Last Name

Address Line 1

Address Line 2

First Name MI Last Name

Address Line 1

Address Line 2

If there are more than TWO defendants, please provide the name and address of the additional defendants in the "Comments" section at the bottom.

Name of the Agreement

Dealer's Name (as appears on Secretary of State filings)

Date of EXECUTION of Agreement

Date of ASSIGNMENT of Agreement

Year Make and Model*

Vehicle Identification Number (VIN)*

Purchase Price*

Interest Rate*

Amount Owed (Principal and Interest)

as of

Costs

Attorneys' Fees

Court Type* MunicipalCommon Pleas

Which Municipal Court? (e.g., Franklin County, Ohio; Cleveland; Elyria; etc.)

Which Common Pleas Court?