| What Type Of Debtor Is This?: |
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| CLIENT - Business Name: |
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| CLIENT - Contact Name: |
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| CLIENT - Main Number: |
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| Name of the people &/or Business the actual service was provided for?: |
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| Name all the people who are legally responsible for the debt.: |
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If a business, did you obtain a personal guarantor by one of the primary principles of the business?::
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If a business, are they still in business, with the same people you provided this service for? If not, please tell us both the status of the business, and the status of the people this service was provided for.:
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DATE OF SERVICE:
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ORIGINAL BALANCE DUE:
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DATE LAST PAYMENT WAS MADE:
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TOTAL AMOUNT PAID TO DATE:
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EXISTING BALANCE AS OF THE DATE OF SUBMISSION.:
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| SERVICE PROVIDED: |
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| DEBTOR'S ADDRESS: |
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DEBTOR CONTACT INFORMATION (Include all phones numbers, fax numbers, and label them):
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SOCIAL SECURITY NUMBER - DEBTOR:
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DATE OF BIRTH - DEBTOR:
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Please list all other collection agencies, attorneys, or whomever has worked this specific file, other than your office staff.:
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Please mention all of the reasons why this debt has yet to be collected? Problems others have had in the collection process.:
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| Are there any disputes or complaints by the debtor that we need to be aware of?: |
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| Are there any special circumstances (financial or otherwise) that we should be aware of?: |
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| If an individual, where does the debtor work?: |
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| What is the debtors' occupation?: |
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| Please list any other sources of income the debtor has.: |
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Does the debtor own real estate?:
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