Client Collector Questionnaire

Client Collector Questionnaire and Engagement Agreement

Recitals

WHEREAS, Client Name: (the "Client") is the owner of certain accounts receivable and account portfolios described below; and

WHEREAS, Collector Name: (the "Collector") is engaged in the business of debt collection and related recoveries and is willing to provide collection services under the terms and conditions set forth in this Questionnaire and Engagement Agreement effective as of Effective Date: .

WHEREAS the parties intend to memorialize Client's account information, service scope, and the commercial terms that will govern any collection activity.

Scope of Work

Client Information

Individual    Corporation    LLC    Partnership    Other:

Portfolio Details

Typical Average Account Balance:    Expected Monthly Submission Volume:

Consumer    Commercial    Medical    Utility    Telecommunications    Other:

Credit and Collection Authorizations

By signing below, Client authorizes Collector to take the following actions with respect to accounts submitted under this engagement (check all that apply):

Credit reporting to consumer/credit bureaus where permitted by law
Commence or pursue litigation as necessary
Perform skip-trace and locate services
Pursue banking garnishment or levy where permitted
Negotiate and accept settlements on Client's behalf subject to prior approval:

Payment Terms (Engagement)

Fee Structure (select one and provide details):

Contingency percentage: %    Flat fee per account: $    Retainer: $

Late fee (interest) rate per month: %    or Flat late fee: $

Term and Termination

Commencement Date:    Expiration Date (if any):

Confidentiality

Both parties acknowledge that Client will disclose non-public information to Collector in the course of performance. Collector shall (a) maintain such information in strict confidence; (b) use it solely for collection activities under this engagement; and (c) not disclose such information except as required by law or with Client's prior written consent. These obligations survive termination of this engagement for a period of five (5) years.

Governing Law

This Agreement and any disputes arising out of or relating to it shall be governed by the laws of the State of without regard to conflict of laws principles.

Entire Agreement

This Questionnaire, together with any attached schedules and a subsequently executed Engagement Agreement, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, understandings, and communications, whether written or oral. Any modification must be in writing and signed by both parties.

Compliance and Certifications

The Client certifies that it is the lawful owner or authorized agent of the accounts submitted, that all information provided is true and accurate to the best of Client's knowledge, and that Client will comply with all applicable federal, state, and local laws, including those governing debt collection, privacy, and consumer reporting.

Client certifies ownership or lawful assignment of accounts.
Client certifies compliance with applicable laws and licensing requirements.
License / Registration Number (if applicable):

Attachments

Indicate provided attachments:

Assignment(s) of account(s)
Account list / spreadsheet with account identifiers
Copies of underlying contracts / billing statements (if required)
Court judgments / filings (if applicable)

Miscellaneous Provisions

Notices under this Agreement shall be in writing and delivered to the addresses set forth above (or as later designated in writing). If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

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