If interested, please complete the following Premium Rate Account Placement Sheet:

Debtor:
Attention:
Address:
City, State Zip:
Amount  $:
Type of Transaction:
Who did you deal with :
Debtors Phone
Remarks:
The above account is referred to you for IMMEDIATE PERSONAL COLLECTION service at the PREMIUM RATE of 16% of the first $3,000 collected and 14% of the excess.  We understand to qualify for this PREMIUM RATE the account balance must be $2,000 or more and be placed within six months from the due date of the oldest invoice.  On authorized merchandise returns, one half the regular fee will apply.

As our agent, you are authorized to accept payments and endorse checks, or money orders received on accounts for deposit.  The net proceeds of which you are to remit to us upon clearance of the debtor's check.  You are authorized to report accounts we place for collection to a credit reporting agency.

FORWARDING SERVICE:
As our agent, if in your judgment our interests will be best served by your forwarding this account to an attorney, and we have not designated an attorney, you may transmit same for collection to an attorney of your choosing.  The attorney you select shall be our attorney and at all times subject to our direction and control.  Your standard, contingent forwarding commission rate, which includes the commissions of the attorney is 50% of the first $200 collected, 28% of the next $1800 collected and 25% of the excess of $2000 collected.  It is understood our special authorization is required to file suit, compromise, grant extensions or incur any non-contingent expense whatsoever.  We understand the attorney will charge a suit fee when court action has been authorized by us.

Accounts withdrawn or settled direct are subject to charges based on the status of the account at the time.

Claimant:
Address:
City, State Zip:
E-mail Address:
Telephone:
Signature:
Date:
Are additional forms needed:

For general information, please complete the following form:

Name:
Address:
City, State Zip:
Telephone:
Fax:
E-mail:
Comments:

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