Consumer Placement
Form
(Small Business)
CLIENT INFORMATION
Name: ________________________________________________________
Contact Name: _____________________ Position: ____________________
Address: ______________________________________________________
City: _______________________________ State: ______ Zip:
________
Phone: ( )_______________________ Fax: (
)____________________
DEBTOR INFORMATION:
Debtor: _________________________ ssn#: ______________________________
Spouse: _________________________ ssn#: ______________________________
Consumer Drivers Lic.#: State:______ ID#: ______________ Dob:
___________
Spouse Drivers Lic.#: State:______ ID#: ________________ Dob:
___________
Address: ____________________________________________________________
Previous Address:
____________________________________________________
Home Phone #: ( )______________ Work #: (
)________________ Ext: ______
Debtor's Employer: ___________________________________________________
Employers Address: ______________________________ ph#: ________________
Spouse's Employer: ___________________________________________________
Employers Address: ______________________________ph#: ________________
Bank Info: ___________________________________________________________
Checking Account Number: __________________________
Type of Account: Savings ( ) Checking ( ) Other ( )
Account Info: __________________________________________________________
______________________________________________________________________
Other Creditors: _______________________ Account Number:
_________________
Other Creditors: _______________________ Account Number:
_________________
DEBT INFORMATION:
Amount Owed: $__________________ (including interest to date)
Interest Rate: _____________
Other Charges:
Discription of Added Charges:__________________________________
Total Owed: $__________________
Description Of What Debt Is For: ( ) Promissory Note ( ) Check ( ) Credit
Card ( ) or Other:
______________________________________________________________
Reason given for non-payment:
____________________________________________
Is The Account Disputed: Yes:____ No: ____ If Yes Attach
Details.
Has The Account Been With Another Collection Agency, Attorney, or Other
Party For Collections: Yes:____ No: ____ If Yes Attach
Details.
Please Attach Co/Signer information (If Applicable)
Date of last payment: ______________________
Charge off date - Date They Defaulted - Loss date:
__________________
Client account number or reference number:
__________________________________
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