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    Client Informationsss

    Work Number:

    Cell Number:

    Fax Number:

    Work Number:

    Cell Number:

    Fax Number:

    Debtor Information

    Work Number:

    Home Number:

    Cell Number:

    YesNo

    Calculate from date:

    YesNo

    Calculate from date:

    Judgement/Principal

    Date of Judgement

    Date of last charge/Invoice:

    You have consent to call cellular telephone numbers associated with the Account using an Automated Telephone Dialing System, as defined by the Telephone Consumer Protection Act of 1991 (and as amended), 47 U.S.C. § 227.

    YesNoDon't Know

    Additional Information

    Date* of last contact

    Has another agency/attorney previously handled this claim?

    YesNo

    Is the debtor still in business?

    YesNo

    Is there a dispute?

    YesNo

    Has the debtor filed for bankruptcy?

    YesNo

    Is there a personal or co-signer?

    YesNo

    Please fill out the following information:

    Cell Number:

    Work Number:

    Do you have a signed agreement?

    YesNo

    Please Report debt to credit Bureaus*
    **if applicable by statute and/or jurisdiction

    YesNo

    What were your last results when you made your last contact with the debtor?

    Enclosed documents:

    Invoice

    Itemized Statement

    NSF Check

    Contact/Agreement

    Other

    SCHEDULE OF EARNED COMMISSIONS

    between CEDAR HOLDINGS INTERNATIONAL, INC dba Cedar Financial and CLIENT mentioned above

    Rate are based on a percentage of the amount collected by the AGENCY for the CLIENT, The commission structure will be as follows:

    ON ALL ASSIGNED ACCOUNTS:

    All Rates Are Contingent

    25% on all Claims Assigned Pre-Legal

    AGENCY may retain in its entirety any and all allowed additional fees, costs, or additional interest and fees received from the debtor above the balance placed by CLIENT. Fees will be due on all accounts collected, whether paid direct to creditor or to agency, or on accounts withdrawn after our demand has been made. A 3 (three) percent credit card fee will be charged to any credit card transaction listed on monthly remittance statement(s). The credit card transaction fee(s) are charged to CLIENT and offset by the remittance balance due to CLIENT. Credit card transaction fees are not added into any debtor account or charged to the debtor.

    Fees will be due on all accounts collected, whether paid directly to creditor or to agency, or on accounts withdrawn after Agency demand has been made, according to the terms of the Agreement.

    I agree and read the information to the rates and terms.

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