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  • CLAIM PLACEMENT FORM

  • We hereby acknowledge that after the date of assignment all monies collected by the agency or paid direct to the creditor will be subject to the agency's contingent rate schedule and the agency, as the creditor's legal assignee for collection will sign whenever necessary debtor checks on our behalf in order to negotiate with the agency's bank any checks made payable to the creditor. We hereby acknowledge that on occasion. the agency may need to accept debtor payments by credit card and any credit card fees will be deducted from client remittances.

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  • Please include pertinent documents including invoices and/or statements of account

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