Date:      Amount:  

Debtor: 

Address:

Address:

City:       State:   Zip:  

Party to Contact: 

Account No:       

Debtor's Phone No:

Debtor's Bank:    

Checks Returned:  No Yes
   Dispute(Furnished Details):  No Yes

Remarks:



Fax Number: 
E-mail Address: 


Creditor Information

Creditor:
Address: 
 
Address: 
City:        State:   Zip:  
By:      


     

 

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In placing accounts you  authorize us to act as your agent for
collection, contact your debtors, accept and endorse payments for
deposit, and remit net proceeds to you.
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