Fill and Sign the Claim Collection Form

Acceptance of claim—Report of experience with debtor [Letterhead of collection agency] To: ____________________ [name of creditor] ____________________________________________________________ ____________________________________________ [address of creditor] Receipt is acknowledged of your claim against __________________ [name of debtor] for $______________ [dollar amount of claim] , which is the ________________________________________________________________ _____________________________ [balance due/total purchase price/[other circumstances of the debt]] for ______________________________________ [goods purchased/services performed/[other consideration]] . Your claim is accepted for collection under the following terms and conditions: [commission schedule] _____________________________________________. Our experience or contacts with the debtor are shown by check marks preceding the appropriate statements: 1. A personal demand is being made on the debtor and a further report will be made to you in ______ [number] days. 2. The debtor is slow in payment, but it is believed that we can collect your claim without suit. 3. The debtor is slow in payment and generally must be sued. If you desire suit to be filed, please send duplicate invoices, statements of account, and the enclosed affidavit, properly executed, together with your check for $____________ [dollar amount] for advance court costs and suit fee. In the meantime, we will take up the matter with the debtor in an effort to effect an amicable settlement. 4. The debtor generally remits payment to ________ [his/her] creditor immediately on our demand. Kindly keep us advised of direct remittances. 5. The debtor is in bankruptcy. Please execute the enclosed proof of claim and power of attorney and return them to us at once. 6. We have had ______ [number] claims against the debtor and have collected _______ [all/[number]] of them. 7. We now have _______ [number] claims against the debtor and are collecting them by ______________________ [monthly payments/suit/[other mode of collection]] . 8. This debtor generally has a complaint regarding the claim. We suggest you furnish us with additional information concerning the claim and send us all original correspondence, together with any original orders, written acknowledgements of the claim, or promises to pay. 9. This debtor is out of business. The debtor has no property that can be levied on, and the debtor is not earning sufficient wages for garnishment. However, we believe the debtor will pay when it is possible. We will try to persuade the debtor to pay and will keep you advised of material developments, unless you advise us that you desire the claim to be returned to you. Dated: _______________ [date of report] . ___________________ [Signature] ___________________ [Title]