Account Placement Form - LienMaster®

Creditor Information
Your Company's Name / D.B.A*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Debtor Information
Your Reference Number
Debtor's Corporate Name / D.B.A*
Debtor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Debtor's Phone*
Debtor's Fax
Amount Due*
Date Debt Became Due
Name of Contact
First Last
Debtor's Bank Information
Name of Debtor's Bank
Account Number
Address of Debtor's Bank
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Comments / Special Instructions
Miscellaneous
Please check the following boxes that apply:
- Statement / Invoices
- Credit Report
- Contract / Purchase Order
- Notes
- Correspondence
- NSF Check
- Guarantees
- Other
Submitted By*
By submitting this form, you are authorizing MCC / LienMaster to proceed with immediate collection.
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Name
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Creditor Information