Collection Placement

Your Company

Your Name

Your Email

Debtors Name

Debtors Address

Debtors City, State, Zip

Debtor Phone

Debtor Email

Date of First Invoice

Date of Last Invoice

Date of Last Payment

Original Amount

Collection Fee, Lien Fee, etc.*

Interest Amount*

Total balance due

Previous Actions

In-house Collections Other Agency Attorney

Type of Indebtedness

Delinquent Account Lease Deficiency NSF Check Repossession Judgment Product/Service

Reason for Placement

Beyond Terms Disputes Broken Promises Ignoring

Comments

Action Requested

Retain Client Light Action Moderate Action Heavy Action Other Action

Other Action

Upload Documents

* You must have a written contract with a provision for collection fee or interest to add to the balance.

4235 N. 7th Avenue
Phoenix, Arizona 85013
P: (602) 279-3666
F: (602) 279-3789
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