An assignment of beneficial interest in the land trust was signed to secure a loan from:
_________________________________________________________________________________________________
I own: ___ car(s): (make and model) _____________________________ VIN: ____________________________
Lien holder: ___________________________________________________________________
(make and model) _____________________________ VIN: ____________________________
Lien holder: ___________________________________________________________________
(make and model) _____________________________ VIN: ____________________________
Lien holder: ___________________________________________________________________
J
ewelry: (description) _____________________________________________________________________________
_________________________________________________________________________________________________
Stocks/Bonds (name/institution and value) _____________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Income Tax Returns presented for tax years: _____________________________________________________________
Any asset/property not noted above valued over $500.00: ___________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Money people owe debtor:
From Whom:_________________________________________ Amount:$ _____________________________________
From Whom:_________________________________________ Amount:$ _____________________________________
From Whom:_________________________________________ Amount:$ _____________________________________
From Whom:_________________________________________ Amount:$ _____________________________________
Debtor’s Signature(s) _________________________________ _____________________________________________
_________________________________ _____________________________________________
Print Name
Print Name
Dated: ________________________ 20 ____
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171-351 (Rev. 08/12)