Other
We are assigning the above debtor account to you for collection. In the event this account is unable to be collected by your direct collection activity, you are authorized to forward this claim to an attorney. The attorney shall then be subject to our control, and no legal proceedings will be commenced without our authorization. You or the attorney are authorized to accept remittances, and endorse them in our name for deposit and collection.
Please send us the following information, if available to you:
NSF Check
Notes
Credit Report
Guarantees
Correspondence
Contract/Purchase Order
Statement/Invoices
MISCELLANEOUS
COMMENTS/SPECIAL INSTRUCTIONS
3. Account No.:
2. Address:
1. Name:
DEBTORS BANK INFORMATION
Date Debt Became Due:
4. Amount Due:
Date:
e-Mail:
Submitted by:
5. Name of Contract:
Fax:
3. Tel:
Zip:
State:
City:
2. Address:
1. Debtor's exact corporate name and/or d.b.a.
DEBTOR INFORMATION
ACCOUNT PLACEMENT FORM
CREDITOR INFORMATION
2. Address:
1. Your company's exact corporate name and/or d.b.a.
City:
State:
Zip:
3. Tel:
Fax:
State of Incorporation:
4. Brief Description of what your company furnishes:
Attach files to this form