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.
Please choose file(s) you wish to attach to this form:
Drop files here or

Accepted file types: jpg, pdf, doc, png, jpeg.
Phone
This field is for validation purposes and should be left unchanged.

Creditor Information