|
Debtor
Information |
Account Name *
|
DBA
|
Contact Name *
|
Telephone Number,
including Area Code: *
|
Address *
|
PO Box
|
| City *
|
State *
|
Zip Code *
|
| Amount of Claim: * $ |
Please include copies of
invoices or other documents supporting claim amount. |
| Type of
Claim: *
Commercial Account
Consumer Account |
| Does your
customer agreement provide for addition of collection fees to claim
amount? *
Yes
No |
| Does your credit
application or contract allow for interest to be charged? *
Yes
No |
| If so, how much? *
% |
| I agree to pay
the prevailing Collection Rate in effect at the time of
placement. *
Yes No |
| Notes: |
|
Creditor
Information |
Contact Name *
|
Company Name *
|
Address *
|
PO
Box
|
| City *
|
State *
|
Zip Code *
|
Telephone Number,
including area code: *
|
Fax Number,
including area code:*
|
| Email *
|
| How will back up
documentation be submitted? *
Email
Fax
Mail |
