This form is generic and used to submit all debtors

Please fill out as much information as possible, if you don't know the answer or it doesn't apply leave it blank. We may contact you for clarification or more information regarding your answers. If you leave a valid email address or fax number you will receive confirmation from us with in 48 hours.

If you are currently a client and have your client number please enter it below and you may skip the "Your Information" section.

 

Xpert Client #

Your Information

Mr. Mrs. Ms. First Last

Title Company

Street City

State Zip

Phone Number Fax Number

Email Address

What type of service would you like us to perform:

Letter Service
Skip Tracing
Collections

Is this a second placement? Yes No

Debtor Information

Mr. Mrs. Ms. First Last

Social Security Number if Consumer

Company Name

Street City

State Zip

Home Phone Work Phone

Email Address

Debtor's Account #

Principal Balance

Finance Charges to Date

Do we need to continue charging interest Yes No

If So, at what interest rate?

Does your contract allow debtor to pay OUR collection fee? Yes No

Or is the collection fee stated in the contract? Yes No

If you answered Yes please enter the amount

Please indicate which items you can make available to us if needed:

Credit Application Copy of Correspondence Current Statement

Personal Guarantee Contract or Promissory Note Copy of Lien

Invoices: Copy Original

Bad Check: Copy Original

Is this Disputed? Yes No

Mail Returned? Yes NO

Additional Information or Costs

Do you agree to the Terms and Conditions? Type: YES if you agree

How did you hear about us?

Search Engine
Word of Mouth
Mailer
Website Link