Letter of Referral of Claim for Collection : Please fill out the following form. Please print your completed form if you would like to have a copy for your records.
Name of Collection Agency :
The account described herein is referred to you for collection.
Unless we advise you of payment within days, you may proceed withwhatever steps are necessary for collection of this account, subject to the restriction set forth.
Payments collected by you or paid directly to us after the expiration of said period are subject to a collection commission as set forth in your commission schedule.
You are hereby authorized to endorse in our name for deposit and collection all payments received on this account.
It is understood that you are not authorized to initiate legal proceedings with respect to the described account.
If you are unable to collect the amount owed in the account you may return it to us for submission to our attorneys.
DESCRIPTION OF ACCOUNT
Amount owed : $
Date of last charge :
Date of last payment :
Currently employed or active in business? : YES / NO
Debt is owed for :
Other Comments :
STATE OF :
COUNTY OF :
On _______________________ before me _________________________ personally appeared ___________________________ personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Affiant : Known / Unknown :
ID Produced :
Letters for Credit and Collection Index
Letter of Referral of Claim for Collection
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