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Joel Cohen

CLAIM PLACEMENT

You should complete this form for each account that you want to turn over for collection.

    Name of Account

    Address of Account

    Telephone Number of Account

    Amount owed: $

    First and Last Dates of Sales or Work Performed:

    Total Charges for Entire Period:

    Amount Paid, if any:

    Balance Due: $

    Type of Goods Sold or Nature of Work Performed:

    Identify which of the following documents will be faxed or mailed to us:

    Statement of Account Yes   No

    Most recent check from the debtor Yes   No

    Credit application Yes   No

    Correspondence or other written documents Yes   No

    Comments:

    * Your Firm Name: (Required)

    * Person to Contact: (Required)

    * Phone Number: (Required)

    * E-mail Address: (Required)


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