Concord Collection Services Inc.

Concord Collection Services, Incorporated

Professional Debt Recovery Solutions

Place A Claim

Client Information

*Creditor (Your Company):

*Submitted By:

*Your Title:

*Address:

*City:

*State:

*ZIP

*Telephone Number:

Fax Number:

Email:

Web Address:

Attach File:

Debtor Information

*Name:

Customer Number:

*Contact:

Title of Contact:

*Address:

*City:

*State:

*ZIP

*Phone Number:

Fax Number:

Email:

*Amount Assigned:

*Debtor Last Payment:

*Invoice Date:

*Age of Debt:

Experience:

Broken Promises

Ignores All Demands

Inability To Pay

Returned Mail

Disputed (explain below)

Documentation:

Please note that documentation is required for processing to begin.

Credit Application

Itemized Statement(s)

Invoice(s)

NSF Checks

Notes

Credit Reports

Correspondence

Personal Guarantee

Contract

Other

I will be forwarding documentation by: Fax Mail Email

Documentation provided promptly accelerates the collection process.

Special Instructions:

By hitting "Place Claim" you acknowledge that you have read and agree to Concord Collection Services, Inc. "Service Agreement" for claim placement.

*Denotes a Required Field