CLAIM ASSIGNMENT FORM

 
 

Required Field

 
 

 
     
   
 
Today's Date: 
     
 
Client Name: 
     
 
Address: 
     
 
City: 
     
 
State/Province:
     
 
Zip Code: 
     
 
Phone: 
   
 
Fax: 
     
 
Contact: 

   
 
Email: 
     
   
Comments:
   
   
   
   
   
 

 

Send An Attachment If You Wish, e.g., Supporting Documentation
   
 

File: 

   
   

Leave Field Blank If No File Is Attached
   
           
 
 
   
   
 
Debtor Name: 
     
 
Address: 
     
 
City: 
   

 

 
State: 

     
 
Zip Code: 
     
 
Phone: 
   
 
Fax: 
     
 
Contact(s): 
     
 
Email: 
     
           
 
Excluding Interest and Service Charges, How Much is Owed? 
     
           
 
Date of Oldest Invoice: 
      
 
Date Debtor Last Paid You: 
      
           
 
When Did You Last Discuss the Debt With Your Debtor? 

   
           
 
What Does Your Debtor Say When You Ask For Your Money? 

     
           
  What is the basis of this debt? The services or products provided to the debtor. If you have a Judgment, we need a copy of the Judgment:

     
           
  Any Additional Info We Should Know About?      

AGREEMENT
 

I understand the fee arrangements. I realize that if the debt is settled with money, goods, services, or waived by myself or my company after the assignment date, I or my company will be liable for your fee, unless Attorney Collection Services, Inc. (ACS) has closed this claim as uncollectible in writing. I am authorizing ACS to receive and endorse for the purpose of collection, any funds, in all forms received by ACS, and remit same to me, less any fees due ACS.  The terms of this assignment will apply to all assignments from me or my company to ACS.

 

Do You Agree To The Above Terms?

I Agree 

In Order To Continue, You Must
Agree To The Terms Above

If You Have Questions, Please Call Us At (800) 989-9855
 

Signature Block


The "Submit Form" Button Emails Your Claim Assignment. Alternately, Please Print Form, Sign the Printed Form in the Above Space and Fax to:
(800) 808-8538