Your Company's Information

Your Debtor's Information

Spouse / Co-Worker Information

Account Information

By submitting this form, the creditor represents and warranties that it has provided all required Truth in Lending disclosures to each holder listed on this form, and obtained all necessary signatures so as to fully comply with the law. The creditor further agrees to inform the undersigned collection agency upon its receipt of any information which would render the account information contained herein more complete, accurate, or obsolete, including but not limited to, notice of a consumer bankruptcy filing.