experimental form



CREDITOR/YOUR INFORMATION:

CLAIM INFORMATION:






DEBTOR INFORMATION:





Business Owner Information:

ADDITIONAL INFORMATION:

We hereby assign to THE NATIONAL COLLECTION AGENCY, INC., the account listed above, subject to your current commercial fee schedule. It is understood you will not forward or sue without our granting permission. When permission to sue is granted we agree to advance all court costs. All sums collected in addition to the amount listed as due shall be retained by you except court costs advanced by us, which will be refunded only when the account is paid in full.


Verify