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Case #:
Debtor: , Acct #:

RE: VIN#:

Lien holder: Date: 12/7/2021

Personal Property List:

Customer has paid $ to retrieve personal property from recovered vehicle.

Agent Signature Debtor Signature

Witness Signature

(Signature above indicates personal property from recovered vehicle has been returned satisfactorily. This releases
the above-mentioned Recovery agency and Lien Holder from any and all liability concerning said property.)

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