Claim Placement Form

Fill out and Submit the Form below to Place a Claim OR Fill out our PDF form that you can save, email, mail or fax back to us.

Please collect the account contained in this submission. It is correct, just and unpaid, and we can furnish an itemized statement upon request. This account has not been or is not now listed with other collectors or with attorneys to our knowledge. We agree to report to you promptly all payments made directly to us on this account. When this account cannot be collected by peaceable means and your investigation and best judgment indicates that legal action is advisable, you are hereby authorized to assign this account to any person or firm for purposes of legal action, reserving the equitable ownership of this account; and you are hereby further authorized to accept assignments from other creditors of the person or persons listed below to me or for the purpose of legal action only.

Client Information
Client Name*
First Last
Client Number*
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email*
Authorized By*
Title
Check if Yes
- Would you like to have us call and discuss your collection problems?
- Has mail been returned by the post office?
- Is the account disputed?
Debtor's Information
Account Number*
Debtor's Name*
First Last
Debtor's SSN
Debtor's Spouse
First Last
Spouse's SSN
Employer
Phone
Work Phone
Debtor's Address*
Street Address Address Line 2 City State ZIP Code
Date of Last Payment
Date Format: MM slash DD slash YYYY
Date of Last Charge
Date Format: MM slash DD slash YYYY
Amount*
Costs*
Total*
Message
Consent*
By checking this box and submitting this form you Agree to the Terms and Conditions stated in linked document below.*
Agreement for Collection Services
Name
This field is for validation purposes and should be left unchanged.

Fill out and Submit the Form below to Place a Claim OR Fill out our PDF form that you can save, email, mail or fax back to us.

Client Information

Debtor's Information

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Credit Reporting Companies

HIPAA Sites

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