Scribd Logo
Upload

Welcome to Scribd!

  • 45 views

    Claim Submission Form: Your Information

    Uploaded by

    CAST1235
    This document is a claim submission form for Attorney Collection Services, Inc. It requests information about the claimant, the debtor, and details of the claim including the amount owed, dates of invoices and last payment, and notes on collection efforts. By signing the form, the claimant authorizes ACS to pursue collection of the debt on their behalf and take a fee from any funds collected.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Claim Submission Form: Your Information

    Uploaded by

    CAST1235
    45 views2 pages
    This document is a claim submission form for Attorney Collection Services, Inc. It requests information about the claimant, the debtor, and details of the claim including the amount owed, dates of invoices and last payment, and notes on collection efforts. By signing the form, the claimant authorizes ACS to pursue collection of the debt on their behalf and take a fee from any funds collected.

    Original Title

    1

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a claim submission form for Attorney Collection Services, Inc. It requests information about the claimant, the debtor, and details of the claim including the amount owed, dates of invoices and last payment, and notes on collection efforts. By signing the form, the claimant authorizes ACS to pursue collection of the debt on their behalf and take a fee from any funds collected.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    45 views2 pages

    Claim Submission Form: Your Information

    Uploaded by

    CAST1235
    This document is a claim submission form for Attorney Collection Services, Inc. It requests information about the claimant, the debtor, and details of the claim including the amount owed, dates of invoices and last payment, and notes on collection efforts. By signing the form, the claimant authorizes ACS to pursue collection of the debt on their behalf and take a fee from any funds collected.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Fax To: (310) 377-0688 Customer Service Call Toll Free: (800) 989-9855 Page 1 of 2

    Claim Submission Form


    Your Information

    Your First Name: Your Last Name:

    Your Company Name: Your Title:

    1st Address

    2nd Address

    Your City: State: Zip Code:

    Your Email: Country:

    Your Telephone Number Fax Number:

    Debtor Information

    Debtor First Name: Debtor Last Name:

    Debtor Company Name: Debtor Title:

    1st Address

    2nd Address

    Debtor City: State: Zip Code:

    Debtor Email: Country:

    Debtor Telephone Number Fax Number:

    Attorney Collection Services, Inc.


    P.O. Box 2415
    Palos Verdes, CA 90274-4872
    Fax To: (310) 377-0688 Customer Service Call Toll Free: (800) 989-9855 Page 2 of 2

    Claim Submission Form

    Claim Information
    Date of oldest invoice? * Date your debtor last paid you? *

    Excluding interest and service charges, When did you last discuss debt with your debtor? *
    how much is owed? *

    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, Inc. (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.

    Position: *

    Print name: *

    Signature* Date: *

    Referred by?

    Attorney Collection Services, Inc.


    P.O. Box 2415
    Palos Verdes, CA 90274-4872

    You might also like