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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:
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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