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MRG EZ Send To Fast Collections
1
MRG EZ Commercial Collection Assignments
Please complete this form to instantly assign up-to 5 past-due business customers for IMMEDIATE collections.
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2
MRG Sender's Name
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3
1st Past-Due Customer Information
*
Please complete this required field
Please provide the following information on the 1st business customer you'd like to send to immediate collections.
Debtor Company Name
Balance Past-Due
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
Please Select
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
PLEASE CHOOSE THE CONTINGENCY RATE FOR THIS ASSIGNMENT. ADD 5% FOR INT'L CUSTOMERS.
Debtor Full Billing Address, City, State & Zip
Debtor Point-of-Contact Person
Debtor Email Addresses
Debtor Contact Phone Numbers
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4
1st Past-Due Customer Documents
Please attach available documents (statement, invoices etc.) If you prefer to email documents after submission, just click "Next" below.
Drag and drop files here
Select files to upload
Max. file size
: 12.0MB
Browse Files
Please email any files exceeding 12.0 MB
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5
Assign a 2nd past-due customer?
Please click "YES" to assign a 2nd past-due customer into collections. Otherwise click "NO":
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NO
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6
2nd Past-Due Customer Information
*
Please complete this required field
Please provide the following information on the 2nd business customer you'd like to send to immediate collections.
Debtor Company Name
Balance Past-Due
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
Please Select
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
PLEASE CHOOSE THE CONTINGENCY RATE FOR THIS ASSIGNMENT. ADD 5% FOR INT'L CUSTOMERS.
Debtor Full Billing Address, City, State & Zip
Debtor Point-of-Contact Person
Debtor Email Addresses
Debtor Contact Phone Numbers
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7
2nd Past-Due Customer Documents
Please attach available documents (statement, invoices etc.) If you prefer to email documents after submission, just click "Next" below.
Drag and drop files here
Select files to upload
Max. file size
: 12.0MB
Browse Files
Please email any files exceeding 12.0 MB
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8
Assign a 3rd past-due customer?
Please click "YES" to assign a 3rd past-due customer into collections. Otherwise click "NO":
YES
NO
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9
3rd Past-Due Customer Information
*
Please complete this required field
Please provide the following information on the 3rd business customer you'd like to send to immediate collections.
Debtor Company Name
Balance Past-Due
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
Please Select
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
PLEASE CHOOSE THE CONTINGENCY RATE FOR THIS ASSIGNMENT. ADD 5% FOR INT'L CUSTOMERS.
Debtor Full Billing Address, City, State & Zip
Debtor Point-of-Contact Person
Debtor Email Addresses
Debtor Contact Phone Numbers
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10
3rd Past-Due Customer Documents
Please attach available documents (statement, invoices etc.) If you prefer to email documents after submission, just click "Next" below.
Drag and drop files here
Select files to upload
Max. file size
: 12.0MB
Browse Files
Please email any files exceeding 12.0 MB
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11
Assign a 4th past-due customer?
Please click "YES" to assign a 4th past-due customer into collections. Otherwise click "NO":
YES
NO
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12
4th Past-Due Customer Information
*
Please complete this required field
Please provide the following information on the 4th business customer you'd like to send to immediate collections.
Debtor Company Name
Balance Past-Due
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
Please Select
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
PLEASE CHOOSE THE CONTINGENCY RATE FOR THIS ASSIGNMENT. ADD 5% FOR INT'L CUSTOMERS.
Debtor Full Billing Address, City, State & Zip
Debtor Point-of-Contact Person
Debtor Email Addresses
Debtor Contact Phone Numbers
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13
4th Past-Due Customer Documents
Please attach available documents (statement, invoices etc.) If you prefer to email documents after submission, just click "Next" below.
Drag and drop files here
Select files to upload
Max. file size
: 12.0MB
Browse Files
Please email any files exceeding 12.0 MB
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14
Assign a 5th past-due customer?
Please click "YES" to assign a 5th past-due customer into collections. Otherwise click "NO":
YES
NO
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15
5th Past-Due Customer Information
*
Please complete this required field
Please provide the following information on the 5th business customer you'd like to send to immediate collections.
Debtor Company Name
Balance Past-Due
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
Please Select
Please Select
20% - Customer Accounts $5k and up, oldest invoice is aged 0-6 months
25% - Customer Accounts $5k and up, oldest invoice is aged 6-12 months
30% - Customer Accounts $5k and up, oldest invoice is aged 1-2 years
35% - Customer Accounts $5k and up, oldest invoice is aged 2-3 years
35% - ALL Customer Account Balances from $1k - $4,999.99
40% - ALL Customer Account Balances under $1k
50% - ALL aged over 3 years; Out-of-business; Judgments; 2nds (Previously w/other vendor)
PLEASE CHOOSE THE CONTINGENCY RATE FOR THIS ASSIGNMENT. ADD 5% FOR INT'L CUSTOMERS.
Debtor Full Billing Address, City, State & Zip
Debtor Point-of-Contact Person
Debtor Email Addresses
Debtor Contact Phone Numbers
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16
5th Past-Due Customer Documents
Please attach available documents (statement, invoices etc.) If you prefer to email documents after submission, just click "Next" below.
Drag and drop files here
Select files to upload
Max. file size
: 12.0MB
Browse Files
Please email any files exceeding 12.0 MB
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17
Tags
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In Progress
Done
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18
Services Agreement
*
Please complete this required field
As authorized by this electronically submitted form to Miller, Ross & Goldman (MRG), we hereby authorize immediate collection efforts on our company’s behalf. We agree to pay the applicable contingency fee rate for this and all previous and future assignments, whether monies are received by MRG or by our office. We authorize MRG to solicit, accept and deposit payments on assigned accounts, the net proceeds of which MRG shall remit to our company by the 25th of the month following collection of good funds. We agree to pay all contingency fees due to MRG within 10 days from the date invoiced. We hereby certify that accounts placed with MRG are not and will not be assigned for collection with any other 3rd party.
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19
Electronic Signature & Collections Contact
Please enter your full company name and contact information to be used by our team for our regular collection updates. You also acknowledge and agree that this will serve as your company's authorizing Electronic Signature for submitted Assignments, You, therefore, hereby swear and attest that your have the authority to do so, on your company's behalf.
Your Full Company Name (Must match the past-due invoices)
Your Name & Title
Your Direct Contact Phone
Your Email Address
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