CLAIM FORM / ASSIGNMENT OF COMMERCIAL ACCOUNT

Debtor Company
Amount of Claim
Debtor Address
Street Address

 

City

 

State

 

Zip Code
Debtor
Phone #
Debtor
Fax #
Officers of Debtor
Debtor Contact
Please fill-in all requested information about the Debtor Company. Please send any and all information you have about the Debtor including copies of credit applications, contracts, statements, invoices, bills of lading, checks drawn on Debtors' banks, phone logs, etc. The more information you can provide, the higher the chance for recovery.

By signing below*, I agree to be bound by the terms of the Collection Fee Agreement on file at Oleksa Law Office, P.C.

Creditor Name
Phone #
Fax #
Creditor Address
Street Address

 

City

 

State

 

Zip Code
Email Address
Date:
By:
Name

 

Title

 
*If you do not already have a contract on file, please click on the "Contact Us" tab at the top of the page, and request a contract via email.
   
 
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