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Debt Collection Assignment Form

Please include all information that you feel would be helpful to us. Please also send copies of invoices or statements, credit apps, checks and any other backup documents you may have. If you're a medical office, please contact our Client Services Dept. for more information. Note: Fields in red are required.
Step One: Information About You
Your Name:
Account Number: (Current Clients Only)
E-mail Address:
Company Name:
Address Line 1:
Address Line 2:
City:
State:   Zip:
Country:
Phone Number:
Fax: Number


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