Original Creditor (If any)
Primary Contact Name*
Secondary Contact Name
Legal Company name if different
Type of Business---sole proprietorshippartnershiplimited partnershiplimited liability company (LLC)corporation/ Inc. (for-profit)nonprofit corporation (not-for-profit)cooperative.OtherUnknown
Last Known Address*
Total Amount Owed*
Currency*$ U.S. Dollar€ Euro$ Argentine Peso₴ Australian Dollar£ British Pound SterlingR Brazilian Real$ Chilean Peso$ Canadian Dollar元 Chinese Yuan Renminbi₱ Colombian PesoG Ghanaian New Cedi₹ Indian Rupee¥ Japanese Yen$ Mexican Pesoد Moroccan Dirham$ New Zealand Dollar₦ Nigerian NairaS$ Singapore DollarR South African Rand₩ South-Korean Wonk Swedish KronaT Turkish Liraد United Arab Emirates Dirham
Date of last charge/Invoice:*
Client Reference Number/Invoice Number*
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.*
Date of last contact
Has another agency/attorney previously handled this claim?
Is the debtor still in business?
Is there a dispute?
Has the debtor filed for bankruptcy?
Is there a personal or co-signer?
Please fill out the following information:
Do you have a signed agreement?
Please Report debt to credit Bureaus* **if applicable by statute and/or jurisdiction
What were your last results when you made your last contact with the debtor?
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