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ACCOUNT PLACEMENT FORM

   Client ID#

Contact Name

Client Name

Phone#

Fax

Address

City

State

Zip

 

Debtor Name

Address

City

State

Zip

Amount Owed

Invoice Date(s)

Bank Information

Name

Account Number

Is This A Bad Check?

YesNo

If Yes Please Furnish Check#, Bank Name, Amount, Date Returned, Reason Check was Returned

Check#

Bank

Reason for Return

Date

Indicate which of the following are available if needed:

Invoices?                                                        YesNo

Statement indicating current balance due?    YesNo

Credit Application?                                        YesNo

Contracts or Purchase Orders?                       YesNo

Copies of Checks?                                          YesNo

Correspondence Concerning Claim?              YesNo