Home
Overview
Practice Areas
Attorneys
Library
Et Cetera
Search Site
A/R Collection
Contact Us

 

Debt Collection Placement Form

 

Please complete the claim entry form, including all required fields and any additional information that you think would be useful.  Asterisk ( * ) indicates required information.  Commercial claims older than two years cannot be accepted. 

 

Click here to print a faxable version of this form.

Click here to download Adobe Acrobat Reader.

 

Creditor Name:

*Required Fields.

 

Company Name:    *Contact Name:
                 
*Street Address 1:  Street Address 2:
*City: *State:   
      
*Zip Code: *Phone Number:
*Email Address: Fax Number:

 

Debtor Information:

*Debtor Name: Contact Name:
*Street Address 1: Street Address 2:
*City: *State:   
                 
*Zip Code: Phone Number:
Date Of Birth: Fax Number:
Email Address:  
 
Debtor's Employer: Employer's Address:
Employer Phone Number:
 
Bank Information:  Account Number: 
*Balance Due: Date of Last Transaction:

 

Please indicate which documents are available to support your claim. 

 

Invoices Credit Application
Statements  Promissory Notes
Purchase orders Correspondence/ Email
Contract   Delivery Receipts
NSF Check Agreement for Atty-Fees?

 

Comments:

 

Representation will commence upon acceptance of this claim.  You will receive an acknowledgement and email instructions for forwarding the documents.

[ Home ] [ Overview ] [ Practice Areas ] [ Attorneys ] [ Library ] [ Et Cetera ] [ Search Site ] [ A/R Collection ] [ Contact Us ]

© 2001-2008, Fein, Such, Kahn & Shepard, P.C., all rights reserved.
Main Office: 7 Century Drive, Suite 201, Parsippany, NJ 07054 (click for directions)
Phone: 973-538-4700  Fax: 973-538-8234  E-mail: info@feinsuch.com
Click Here to inquire about purchasing Foreclosed Properties
Please see our Disclaimer and Privacy Policy