Credit Service Company
Professional, Affordable Collection Services
Billings, MT:
(406) 252-6371
Toll Free:
1-800-231-1971
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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.
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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.
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*
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Client Number
*
Address
*
Street Address
Address Line 2
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Debtor's Information
Account Number
*
Debtor's Name
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Debtor's SSN
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Last
Spouse's SSN
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Phone
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*
Street Address
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City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
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Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Last Payment
Date Format: MM slash DD slash YYYY
Date of Last Charge
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Amount
*
Costs
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Total
*
Message
Consent
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By checking this box and submitting this form you Agree to the Terms and Conditions stated in linked document below.*
Agreement for Collection Services
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