Claim Placement Form

      Debtor Name

SSN

Address 1

Address 2

Amount Due$

Debtor's Bank

Your File Number

Home Phone

Work Phone

Fax

Mail Returned Yes   No

 
E-mail

Debtor History - Please Check All That Apply

No Response Check Returned Disputed 
Claims Inability To Pay Phone Disconnected Other
Other

Please Include Any Additional Information In The Box Below

  Creditor Information

Full Name

Title

Company Name

Address 1

Address 2

Phone

Fax

E-mail

Terms and Conditions

Please institute no proceedings, incur no expenses, make no compromises and/or grant extensions without written authorization.   All payments less your commissions must be remitted as received.  Collect interest wherever possible.  Claimant prefers all correspondence be conducted through our office.

This account is forwarded in accordance with the operative guides and receivers adopted by the commercial law league of America, to which we subscribe.  Failure to acknowledge claim, answer letters, or follow claimants instructions, will leave claimant free to recall this claim without payment of commissions to you.  Report promptly the possibility of collections.  If suit is advisable, state exactly what papers and cost you will require.  Charges and disbursements due on other claims must not be deducted from the amounts collected on this claim.

If these terms are not acceptable, please return immediately stating the reasons.  Please acknowledge receipt, stating whether the terms and conditions are satisfactory.