[Name]

Date: _______________

I, [Name], hereby authorize [Lender Name] to sell the collateral item or vehicle,
[description], that I have used to secure a promissory note for hospitalization bills. I
understand that the sale of the collateral item or vehicle is necessary to cover the outstanding
debt owed to [Lender Name].

I acknowledge that I have received the required medical treatment and am appreciative of the
assistance provided by [Lender Name] in covering the hospitalization bills. I authorize
[Lender Name] to sell the collateral item or vehicle to cover the remaining balance of the
promissory note and any associated expenses.

I understand that I will not be able to reclaim the collateral item or vehicle once it is sold and
that I will not hold [Lender Name] liable for the sale or any loss incurred. I release [Lender
Name] from any further claims or obligations related to the collateral item or vehicle.
Signed,