Name of Bank or Business receiving the collected debt payments
| Address | City | ||||
| State | Zip | ||||
| Phone | |||||
| Fax | E-mail * | ||||
Person authorizing collection
Contact person or department to be put on collection letters (optional)
Do you want to add the collection
package price to the amount owed to you?
Please Select
Yes No
Debt is for:
(Example: overdraft, non-sufficient funds, past due account, etc.)
Debtor information ( the one who owes you money ): Place all debtor information in the box below. Please include name, address (city, state, zip), amount owed, and debtor account number (if applicable). This information may also be submitted via mail, fax, or e-mail in most any format you supply (computer printout, customer account forms, written note, etc.).
Total # of debtor accounts sent*
Collection Package Price $
Total paid to Lorkins Associates for collection packages $
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* required field