Name:

E-mail:

Company:

Address:

City:

State:

Zip:

Telephone:

Fax:

Debtor Company

Address:

City:

State, Zip

Balance Owed:

Date of last payment:

Interest or other charges:

Total to collect:

Name of Debtor:

Title:

Name of Debtor:

Title:

Bussiness Phone:

Other Phone:

Bank Name:

Bank Account#:

Type of Business:

Corporation
Partnership
Sole Proprietorship
Other

Collection Activity:

Broken Promise
NSF Checks
Dispute
Out of Business
Skip

Enclosures:

Statements
Invoices
NSF Checks
Bill of Lading
Credit Report