COMPLAINT DEALER ASSIGNMENT QUESTIONNAIRE

PARTIES

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

YesNo

Defendants*

Co-Defendant*

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

AGREEMENT

Description of Vehicle

AMOUNT OWED

COURT DETAILS

RELATED DOCUMENTS & COMMENTS

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Loan SummaryNoteSecurity AgreementOther