Commercial Placement
Form
(Small Business)
CLIENT INFORMATION
Name: ________________________________ Contact: _______________
Address: ______________________________________________________
City: _______________________________ State: ______ Zip:
________
Phone: ( )_______________________ Fax: (
)____________________
DEBTOR INFORMATION
Name of Debtor: ______________________________________________
Last Known Address: __________________________________________
Last Known Phone #: __________________ Fax #: __________________
Business Entity: ( ) Proprietorship ( ) Partnership ( ) Corporation
If Proprietorship, doing business as:________________________________
If Partnership, name of partner(s): _________________________________
If Corporation, name of all known shareholder(s) and officer(s):
__________________________________________________________________
__________________________________________________________________
Any Personal Guarantor: Yes______ No_______
If so, name of Guarantor (please attach copies of Guaranty):
Principal amount owed: $_____________
Accrued Interest: $_____________
Interest Rate: (other than legal rate of 10%): ___________
Total Owed: $_____________
Name of Bank (including Branch): ____________________________________
Account #: __________________________
Address of any other business location: ________________________________
Date customer attempted to cancel the contract:
_________________________
Was the customer delinquent at the time of the attempted cancellation?
_______
Conditions, if any, under which you are willing to continue to do business
with the customer?
__________________________________________________________________
__________________________________________________________________
Settlement authority (if any): ____________ i.e. percentage or dollar
amount
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