Place Account Form

Account/Reference Number:

Starting Balance:

Interest/Fees/Finance Charges:

Total Debt:

Company Name (Debtor):

Personal Guarantor:

Contact Name:

Address:

City:

State: [Choose One] Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:

Telephone: Moblie: Fax:

E-mail Address:

Invoices Faxed? Yes No

Mail Returned? Yes No

Date of Original Balance: D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 M Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec Y 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989

Date of Last Payment:D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 M Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec Y 2004 2003 2002 2001 2000 1999 1998 1997 1996

Social Security: Co. Federal ID#:

Was this account previously assigned to another Agency or Attorney? Yes No

If yes, what is the name of the previous Agency or Attorney?

Additional Comments:

Client Name:

Address:

City:

State: [Choose One] Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:

Phone: Fax: