Please accept the following claim for collection.
* indicates a required field
Debtor Information:
Account#
*
Balance
*
Debtor
Entity
Corporation
Individual
Partnership
Name(s)
*
Address
*
City
*
State
*
Zip
Phone
Fax
Home Phone
E-mail
Bank
Last Invoice
mm
01
02
03
04
05
06
07
08
09
10
11
12
/
dd
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
yyyy
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Enclosures
None
Contract
Promissory Note
Personal Guarantee
Bad Check(s)
Itemized Statement
Other Documents
Mail
File Upload
Files
We can accept up to 3 files. 15MB total (15728640 bytes)
Acceptable file types: csv, doc, pdf, rtf, tif, txt, xls or zip
Comments
Assigned By:
Date
*
Creditor
Name
Title
Address
City
State
Zip
*
Phone
E-mail
I would like a confirmation sent to my e-mail provided above.
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© 2006 JNA Jonathan Neil & Associates, Inc.
18321 Ventura Boulevard, Suite 1000, Tarzana, Ca. 91356
(800) 331-6333 or
mail@jnacollect.com
