ACCOUNT LISTING FORM The account listed below is submitted for collection at your usual rate.
* Required Fields Company Name* E-Mail* Address* City State Zip Code Phone Number* Submitted by*
Please include as much information as available below: Your Account Number Debtor's Full Name* Social Security Number Date of Birth Spouse's Full Name Social Security Number Date of Birth Purchaser or Patient (minor) Social Security Number Date of Birth Last Known Address* City State Zip Code Home Phone Name of Business or Employer Work Phone Address City State Zip Code Spouse's Business or Employer Work Phone Address City State Zip Code Collection Amount* $ Date of Last Charge* Date of Last Payment Is Mail Returned?* YES NO Additional Information: Please call me to discuss our collection problems. . By submitting this form the creditor represents and warranties that it has provided all required truth in lending disclosures to each account holder listed on this form, and obtained all necessary signatures so as to fully comply with the law. The creditor further agrees to inform the undersigned collection agency upon its receipt of any information which would render the account information contained herein more complete, accurate, or obsolete, including but not limited to, notice of consumer bankruptcy filing.
Additional Information:
Please call me to discuss our collection problems.
. By submitting this form the creditor represents and warranties that it has provided all required truth in lending disclosures to each account holder listed on this form, and obtained all necessary signatures so as to fully comply with the law. The creditor further agrees to inform the undersigned collection agency upon its receipt of any information which would render the account information contained herein more complete, accurate, or obsolete, including but not limited to, notice of consumer bankruptcy filing.
