Please enter your information here:
Fields marked with * are required.
Your Name *
Your Company *
Your Phone Number *
Your Address *
Your City, State, Zip *
Your Email *
Please enter your debtor information here:
Debtor Name *
Debtor Company *
Debtor Phone *
Debtor Address *
Debtor City, St., Zip *
Debtor Email
Date of oldest invoice? *
Date your debtor last paid you? *
Excluding interest and service charges, how much is owed? *
When did you last discuss the debt with your debtor? *
What does your debtor say when you ask for your money? *
What is the basis of this debt? The services or products provided to the debtor. *
Any additional information we should know about?
I understand the fee arrangements. I realize that if the debt is settled with money, goods, services, or waived by myself or my company after the assignment date, I or my company will be liable for your fee, unless Attorney Collection Services (ACS) has closed this claim as uncollectible in writing. I am authorizing ACS to receive and endorse for the purpose of collection, any funds, in all forms received by ACS, and remit same to me, less any fees due ACS. The terms of this assignment will apply to all assignments from my company to ACS.
I Agree
Your Name: *
Position and Title: *
Date: *
Referred by?