Collection of Unpaid Invoice by iqg56572

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									                     COMMERCIAL COLLECTION PLACEMENT FORM

To:             Michael S. Baim, Esq.

From:
                ______________________________
                ______________________________
                ______________________________
                Phone:
                Fax:

WE ARE PLACING THIS CLAIM WITH YOU TO COLLECT THIS ACCOUNT DUE OUR
OFFICE:

Name of Debtor(s):      ______________________________

Debtor's Address:       ______________________________

                        ______________________________

Telephone Numbers:      ______________________________

Fax Numbers:            ______________________________

Contact Person(s):      _______________________________

Amount Due:             $______________________________

     WE ENCLOSE THE FOLLOWING SUPPORTING DOCUMENTS TO ASSIST IN THE
COLLECTION OF OUR CLAIM: (DO NOT SEND ORIGINALS):

                _____   Current Statement of Account
                _____   Copy of Each Unpaid Invoice
                _____   Credit Report and/or Credit Application
                _____   Is this claim disputed?
                                  If so, please provide details

Fees: Contingent fee does not apply to defend any counter-claim. Client agrees to advance all costs necessary
to file suit or effectuate collection. By placing this claim with our firm, you authorize us, as your agent, to
endorse any checks we receive on your behalf and to deduct our legal fees. Please contact
Mr. Baim to confirm receipt and to confirm fee arrangement.

By: ___________________________                           Date: __________________

								
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