cln collection agency claim form

Professional Collection Specialists

Type	New CLIENT	Client Number ( IF KNOWN )
Claim Amount	Date Due	Claim Disputed

Creditor Information
CLIENT (Company Name)
Contact Person(s)	Title
Mailing Address
City	State
Zip	Email Address
Telephone Number	Fax Number
Debtor Information
Type of Business:
Company or Individual Name (Debtor)
DBA
Mailing Address
City	State
Zip	Email Address
Telephone Number	Fax Number
Person to Contact	Title
Comments
Indicate which of the following are available if needed (We will contact you if we need them)
Statement showing current Balance Due	Correspondence Concerning Claim
Unpaid Invoices	Copies of Checks
Contract, Purchase Orders	Credit Info.