CUSTOMER INFORMATION
First Name:            Last Name:
  
Address:

City:              State:
  
ZIP or Postal Code: 
 
Country:           Residence Telephone #:
  
E-Mail Address:

Business Phone #:     Return Mail?:
     
        YES            
        NO                           

Employer:          Business Address:
  
SSN#:               DOB:
  
Dr. Lic. (State & No.):

Date of Last Charge:     Date of Last Payment:
            
Balance Owing:   

Notes: 
 



PLEASE ATTACH ALL BACK-UP MATERIAL!

*The above claims are assigned to you for collection at the 
contingent fee agreed upon. We understand that necessary costs 
will be advanced by you at your own risk. Interest to be 
retained by you as additional compensation. As assignee, you are 
authorized to endorse checks and/or money orders drawn to our
order for payment of these accounts. We affirm that the amounts 
shown are due and owing.


*Contact Office Regarding Rates


Client ID #:

Creditor:           Phone #:
  
By:                 Address:
  
Date:


*NOTE: PLEASE ATTACH COPIES
OF THE JUDGMENTS OR COURT ORDERS.