Please provide the following client information

Company Name
Authorized By
Your Name
Type of Industry
Street Address
Address (cont)
City
State/Province
Zip/Postal Code
Country
Work Phone
Work Fax
Your Email

Please provide the following debtor information

Debtor Company Name
Responsible Party
Type of Industry
Street Address
Address (cont)
City
State/Province
Zip/Postal Code
Country
Telephone
Fax
Debtor Email
Amount Owed
If debt consists of several invoices, please check one of the following
None
Attached
Enroute
If you have been working with one of our professional reps, please enter their name here:
Comments and debtor history. Please, if possible cut and paste all pertinent documentation to support your claim (invoices, proof of delivery, letters of correspondence).

Thank you for the opportunity to collect your bad debt accounts. We will keep you informed of all significant developments.