Contact Information
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Firm Name
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Email
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Client Account Number
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Address
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City
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State
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Zip Code
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Phone
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Submitted By
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Debtor Information
Please include all debtor information available.
Responsible Party First Name
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Responsible Party Last Name
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Responsible Party Birth Date
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Month
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Day
Year
Date
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Responsible Party Social Security Number
Name of Spouse
Last Known Address
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MT
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ND
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OR
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Zip
Home Phone
Cell Phone
Work Phone
Business/Employer Name
Employer Address
Employer City
Employer State
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IA
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IL
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KS
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LA
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MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Employer Zip
Name Debt Relates To
Account Number
Collection Amount
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Insurance Provider (if applicable)
Did Insurance Pay? (if applicable)
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Date of Last Service
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Month
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Day
Year
Date
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Date of Last Payment
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Year
Date
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Is Mail Returned?
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Additional Information
Email Receipt
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