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Rate Schedule
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Debtor Information
Type of Debt
Open Invoice
Late pay
Debtor Account #
(your file# for this account)
Free Demand
Amount
Company Name
Contact
Date of Transaction
Address
City, State, Zip
Phone
Fax
Briefly describe the nature of the collection problem and the circumstances involved
Client Information
*
Name
Address
City, State, Zip Code
Email
*
Phone (example 212-555-1212)
Contact
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.
*
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