Please use the form below to place an account for immediate collection.
Once you have submitted the account information, we will begin the collections process immediately.

Debtor Information All Required Information

Debtor Company Name
Amount Owed	(we can only accept accounts of $500 or more without prior corporate authorization)
Date Incurred	(date of invoice, last sale, or service rendered)
Date of Last Payment	(on delinquent account if any)
Invoice Number	(if applicable)
Address
City
State	Choose a State Alabama Alaska Arizona Arkansas Armed Forces Americas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming      Zip:
Phone
Fax
Contact Person
Contact Person's Title
Customer Number
This information will aid us in understanding your situation and your debtor. (Please check all that apply) They avoid contact (always in a meeting, out of the office, etc.) They will not return calls/messages. They dispute the bill or request additional invoices. There is a personality clash and they won't communicate with you. They broke their promise to pay sometime in the last 30 days. You made concessions and they still won't pay.
Remarks, Additional Facts, or other information

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Your Information Required

Client Company Name
Address
City
State	Choose a State Alabama Alaska Arizona Arkansas Armed Forces Americas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming      Zip:
Contact Person
Phone
Fax
Email

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Other Important Information Required Information

Agreement:	Select an option Accept Do not accept I/we have agreed to your terms and conditions.
Account Representative	Choose your Account Rep Troy Service None David Robles Cherish Newman Bridgette Weatherspoon Linda Manning