Assignment Form
For Single Assignments

If you have multiple placements, are a commercial or retail business with a large inventory of accounts, or prefer to speak with a representative you can do so during the business hours of 8:00 a.m. to 5:00 p.m. Pacific Time by calling 866-690-2677. For online submissions of multiple assignments, use the Multiple Assignment Form.

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Company or Your Information

Company Name:

Contact Name:

Company Phone:

Contact Phone:

FAX:

E-Mail:

Type Of Business:

Business Street Address:

Mailing Address:
If different

City:

Mailing City:

State:

Mailing State:

Zip:

Mailing Zip:

Debtor Information

Debtor Name:

Debtor Contact Name:

Day Phone Number:

FAX Number:

Home Phone Number:

Cell or Message Number:

Last Known Address:

Name of Nearest Relative:

City:

State:

Zip:

Debt Amount

Amount Owed To Your Business:

Date of Last Charge:

Reason Money Is Owed: (Explain)

Date of Last Payment:

Documentation To Validate Your Claim:
(Check All That Apply)

Invoice(s)

Statement(s)

Proof Of Delivery

Bad Check(s)

Judgement

Credit Application

Rental Agreement

Other ...

Steps Taken To Recover Debt:
(Check All That Apply)

Messages Left With No Response

Phone Number No Longer In Service

Sent Notices

Debtor Made Recent Promist To Pay, Which Was Broken

Previously Placed In Collections With Another Agency