Type of Debt
Debtor Account #
(your file# for this account)
Date of Transaction
City, State, Zip
Briefly describe the nature of the collection problem and the circumstances involved
City, State, Zip Code
Phone (example 212-555-1212)
Please Upload SINGLE Supporting Document
NOTE: If you have multiple documents, please send a separate email with those attachments.
I have read and understand the terms and conditions of the service schedule. I authorize American Credit Systems, Inc. to proceed with collection activities based upon terms and charges indicated.