Debtor Placement Form
IMPORTANT NOTICE:
Please provide copies of all Invoices, Statements of Account, Credit Application, Personal Guarantees and Promissory Notes on each account placed for collection.
NSF CHECKS:
Please provide copies of checks (front and back).
Your Information
Client Name:
Contact Person:
Date Assigned For Collection:
Street Address:
City:
State:
Zip:
Work Phone:
Fax:
Email Address:
Debtor Information
Debtor Name:
Street Address:
City:
State:
Zip:
Contact Person:
Guarantor:
Home Phone:
SS#:
Work Phone:
Email Address:
Cell Phone:
Fax:
First Invoice Date:
Last Invoice Date:
Principal Amount Due:
Charges, Interest, Etc:
TOTAL DUE:
Debtor History/Comments:
Site Information
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Allied Collection Resources
P.O. Box 46056
Houston, TX 77210-6056
Local:
972-562-7157
Toll Free:
866-490-6989
Fax:
469-519-2384
Email:
Niles@AlliedCollection.com
Great American Insurance Company Bond No:
3724079