Debt Collection Submission Form

Debtor Information
Collection Target Type*

BusinessIndividual
Debtor / Contact Name*

First NameLast Name
Co-Debtor (if applicable)

First NameLast Name
Business Name (if collecting from a business)
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number (If no current phone number, enter the last known number)*
Please enter a valid phone number.
Alternate Phone Number(s)
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth (Optional — if you have it)

MonthDayYear
Date
Social Insurance Number (Optional — if you have it)
Debt Details
Balance Owing*
Invoice Date*

MonthDayYear
Date
Your Account Number (Not mandatory)
Last Payment Date (Leave blank if no payments made)

MonthDayYear
Date
Attachments & Documentation
Upload Supporting Documents (e.g., contract, invoice, statements, receipts)*

Cancelof
Dispute / Communication History
Is there a dispute?*

YesNo
Last Communication & Notes: Provide summary of latest contact, issues, reasons for non-payment, or extra contacts (phone or email)
Authorization & Acknowledgement
We authorize CD Credit Solutions Ltd. to begin collection as of this date. If the debtor contacts us, we will redirect them to CD Credit Solutions Ltd. We will report any payments received immediately. All information provided is accurate, and no additional fees beyond applicable interest have been added. While with CD Credit Solutions Ltd., we will not contact the debtor ourselves.*
Submitter / Your Information
Your Company Name (Use the same name as under your collection agreement)*
Your Name (First & Last)*

First NameLast Name
Your Phone Number (Use the phone listed in your agreement)*
Please enter a valid phone number.
Your Email Address (Use the email from your collection agreement)*
example@example.com
Should be Empty:

Debtor Information

Debt Details

Attachments & Documentation

Dispute / Communication History

Authorization & Acknowledgement

Submitter / Your Information