| *Vehicle Year |
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| *Vehicle Make/Model |
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| *Original Loan Date |
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| *Current Loan Balance |
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| *Auto Loan Term |
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| *Current Interest Rate |
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| *Current Monthly Payment |
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| Estimated Value of the Vehicle |
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| Current Mileage of the Vehicle |
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| Current Lender |
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| Number of Payments Remaining |
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| Comfortable Payment Amount |
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| Are you a Connex Member? (Choose One) |
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| If yes, Connex Account Number |
|