Michael C. Brown, President* ACCOUNT PLACEMENT FORM #PAGES FAXED: CREDITOR INFORMATION 1. Your company's exact corporate name and/or d.b.a. 2. Address: City: State: Zip: 3. Tel: Fax: DEBTOR INFORMATION 1. Debtor's exact corporate name and/or d.b.a. 2. Your reference number: 3. Address: City: State: Zip: 4. Tel: Fax: 5. Amount Due: 6. Date Debt Became Due: 7. Name of Contact: 8. DEBTORS BANK INFORMATION 1. Name: 2. Address: 3. Account No.: 9. COMMENTS/SPECIAL INSTRUCTIONS MISCELLANEOUS Please enclose the following information, if available to you: We are assigning the above debtor account to you for collection. In the event this account is unable to be collected by your direct collection activity, you are authorized to forward this claim to an attorney. The attorney shall then be subject to our control, and no legal proceedings will be commenced without our authorization. You or the attorney are authorized to accept remittances, and endorse them in our name for deposit and collection. Submitted by: Signature of authorized agent for Creditor e-Mail: Please print name and title: Date: Attach files to this form
PLEASE CLICK ON THE "SUBMIT THIS FORM" BUTTON ABOVE, OR FAX OR EMAIL THIS FORM TO INITIATE ACTION
23240 Chagrin Blvd., #410 - Cleveland, Ohio 44122
Telephone: (216) 464-6700 - Facsimile: (216) 464-3840
orders@lienmaster.com - www.lienmaster.com
LienMaster is a division of Master Credit Consultants, Inc.