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Reference Number *

Please tell the date of loss: *

Year *

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On this date with the owner information listed above, removed Personal Belongings from vehicle, and authorized payment to South Coast Towing Inc for charges incurred thru date of removal from storage yard, for listed above.

AUTHORIZATION FOR PAYMENT FOR: TOW, STORAGE, MILEAGE AND ANY / ALL INCIDENTAL CHAGED INCURRED. THE RELEASE IS A CONTRACT WITH LEGAL CONSEQUENCES AND I HAVE READ IT CAREFULLY BEFORE EXECUTING THE SAME.

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