Ross, Stuart & Dawson, Inc.
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PAY YOUR BILL
Placement Request Form
Urgent Action
Final Notice
(please mark which service you prefer)
Debtor Information
Account Name:
DBA:
Contact Name:
Phone #:
Address:
Fax #:
City, State, Zip:
E-mail:
Please include copies of invoices or other documents supporting claim amount
Amount of Claim:
Type of Claim:
Commercial Account
Consumer Account
Does your customer agreement provide for the addition of collection fees to the claim amount?
Yes
No
Does your credit application or contract allow for interest to be charged?
Yes
No
I agree to pay the prevailing Collection rate in effect at the time of placement.
Yes
No
Notes:
Creditor Information
Company Name:
Contact Name:
Address:
Promo Code:
City, State, Zip:
E-mail:
Phone:
Fax:
Signature:
(print your name)
Date:
send