Place Account

Client Information (Creditor)
Company Name *

Your Legal Business Name
Contact Name *
Address
Phone *
E-Mail *
Agent Name *
Debtor Information
Debtor Company Name *
Contact Name *
Phyical Address *
Phone *
Fax
E-Mail
Additional Contact Info
Date of Most Recent Sale/Payment *
Balance Owed *
Comments *

Brief Summary of reason for non-payment...
Personal Guarantee (PG)

YES (Attach a Copy) NO

Did the debtor sign a personal guarantee???
Still In Business *

YES NO

Is the debtor still in business???
Invoices
Statement
Credit Application / PG
Additional Back-Up

By submitting an account for collections using this form you hereby authorize Tucker, Albin & Associates (TA&A) to begin IMMEDIATE collection activities. Please report all payments promptly. Should the debtor attempt to contact you directly you hereby agree NOT to comunicate with the debtor and will refer them back to Tucker, Albin & Associates. Cancelling/Withdrawaling an account submitted for collections will result in full commission to be due (TA&A).

Thank You For Your Continued Trust!!!
Should be Empty:

Debtor Information