Collection Submission Form

Debtor Information
Name of Debtor or Contact Person if Business

First NameLast Name
Name of Co-Debtor if applicable

First NameLast Name
Address: (if the debtor's address is unknown please type "unknown"

Street Address

Street Address Line 2

CityProvince

Postal
Phone Number:
If no Phone Number, please enter last known numberFormat: (000) 000-0000.
Other Number:
If no Phone Number, please enter last known numberFormat: (000) 000-0000.
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDOB if you have otherwise leave blank
Do you have an email for the consumer?
E-mail:
Please enter an email if you have one. It significantly improves our chances of reaching the debtor. Leave blank if you don't have one; do not type N/A.
Name of Business (Only if we are collecting from the business)
Company Name

Debt Details
Balance Due:
Do you charge interest on this account?
Please note: ICON is only legally authorized to add interest if your original invoice or agreement with the customer provides for it. Where it does, we apply interest at 10% per annum from the date of placement. If your invoices do not charge interest, we cannot legally add any — the balance will remain as submitted.
Invoice Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearAccount Eligibility: We do not accept accounts older than three years from the date of the original invoice.
Last Payment Date (leave blank if none)

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Any Dispute on File?
Promo Code (if applicable)
Please provide your last communication and any important notes regarding your customer and the reason they have not paid or if there any additional phone numbers or emails

Authorization & Submit
We authorize ICON to begin collection efforts on this account effective today. Should the debtor contact us directly, we will redirect them to ICON and report any payments we receive immediately. We confirm that all information provided is accurate, that no additional fees have been applied beyond any applicable interest, and that the consumer being placed into collections is over 19 years of age. We understand that, while this account is active with ICON, we will not communicate directly with the customer.
Authorization Statement
File Upload

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Submission Form: