Name

First Name

Last Name

Phone

(###)

###

####

Contact Information

Do you have contact information for this debtor?

Name

Email Address

Postal Address

Phone Number

Copy of ID

I do not know where the debtor is

Disputed

Is this debt disputed?

Yes

No

Signed Agreement

Is there a signed agreement, contract or terms of trade between yourself and the debtor?

Yes

No

If yes, does this include a costs recoverable clause?

This should look something like 'you will be liable for the costs of, and incidental to, recovery of unpaid funds'

Yes

No

Do you hold a personal guarantee?

This is relevant for company debts

Yes

No

When did the debt occur?

What date did the debt occur? If you have multiple debts please give us the date of the oldest debt

MM

DD

YYYY

Have you previously used a collection agency to collect the debts?

Yes

No