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    Who Is Your Service Rep?*

    Your Information

     

    *Your Company Name Or Client Number:

    *(Required) Client Number:

    Your Debtor Information

     

    Debtor Type:

    Debtor Company Name:


    *Do not use debtor place of employment for consumer claims

    Debtor First Name:

    Debtor Last Name:

    Address:

    City:

    State:

    Zip:

    Daytime Phone:

    Evening Phone:

    Fax Number:

    Email Address:

    Debtor Employment:

    Amount Owed(*):

    Date Debt Incurred:

    Tax ID or SS Number:

    Was there a signed Contract?

    YesNo

    Do You Have Backup Such As Invoices:

    YesNo

    Is This A Judgment:?

    YesNo

    If Yes, Date Judgment Was Awarded:

    Product Or Service Provided:

    Reason for Non-Payment:

    Additional Information:

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