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Client Information

Debtor Information

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

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