COMPANY INFORMATION Your Co. Name Date Your Name Phone Email DEBT CONTACT INFORMATION Debtor Name Address City State Zip Phone No.(s) Debtor Contacts DEBT INFORMATION Date of: First Invoice Last Invoice Last Payment Original Balance Charges (Interest, etc.) Total Amount to Collect # of Invoices Rate Assigned  Previous Collection Activity:  In-House  Agency  Attorney  Type of Indebtedness:  Delinquent Account  Lease Deficiency  NSF Check  Repossession  Judgment  Product/Service  Reason for Placement: Beyond Terms  Disputes  Broken Promises  Ignoring  Described below  Action Requested:  Retain Customer  Moderate  Heavy  Other    (desc. below)  Backup Information to be:  Faxed    Mailed    Express    Email