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CASE ASSIGNMENT FORM

Debtor Information
Last Name First Name
Company Name Type
Street Address
City State Zip
Phone No. (s) Your client ref. No.
BUS:  
RES : 
CELL:
Debtor's Tax ID/SS No. Date of Last Charge Date of Last Payment
Principle balance amount(before interest/finance charges) Date of First Debtor Transaction
Name of Bank Branch Account
Client Information
Client
Your formal legal name
Street Address
City State Zip
Contact
Phone Fax Email
Your Contract Interest Rate

To assist you in handling this claim, we are attaching:
Statements Invoices
Credit Reports Copies of Correspondence
Original Order We have no other info

Please start collection on this matter immediately, at 33.3% contingency for demand collection of the principal amount. We will report any direct payments as soon as possible.

Reinstatement of contract, acceptance of return merchandise or cancellation of account will be charged at 1/2 of assigned rate.

I have read, understood, and agree to the rates as stated above and agree that any future claims asigned to you will be subject to the same terms.
Initials Date