Account Placement Form

Debtor Information:

Client ID

Amount

Fees $

Company Name (required)

Total $ (required)

Address

Phone

City

State (required)

Zip

Cell

Contact Name

Email

Backup Information Provided or Available
InvoicesCredit ReportPersonal GuaranteeCredit applicationStatementsCollection NotesOriginal ChecksAdditional Backup

Remarks

Reason Debtor is Not Paying

Client Information:

Client’s Company Name (required)

Client Acct.

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Fax

Email (required)

Assigned By (required)

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