Online Placement

CLIENT INFORMATION

PRINCIPAL/DEBTOR INFORMATION

COMPANY CONTACT

Disputed

Phone Disconnected

Offer to Pay

Inability to Pay

Breach of Payment Agreement

Bankruptcy

Mail Returned

Other

Yes

No

Yes

No

Yes

No

1. Indemnitor/Personal Guarantor Information:

2. Indemnitor/Personal Guarantor Information:

3. Indemnitor/Personal Guarantor Information:

4. Indemnitor/Personal Guarantor Information: