Briefly describe the type of accounts to be sent into collection:
Anticipated volume to be placed:
Dollar Amount:

Number of Accounts:

Future Placement Frequency:

Previous collection efforts on these accounts: (What has been done to collect on these accounts?)
Average age of accounts; (how many days past due)?

What information/backup do you have for the accounts? (Contracts, statements, original signed documents, etc.) What computer system is the information stored on?
Contact Information
Name:

Title:

Company:

Address:

City:

State:

Zip:

Email:

Website:

Phone:

Fax:

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