Debtor Information
*
Debtor Company Name:
Debtor Account #:
*
Address:
*
City:
*
State:
*
Zip:
*
Telephone #:
e.g. (XXX) XXX-XXXX ext XXXX
Additional Telephone #:
e.g. (XXX) XXX-XXXX ext XXXX
Fax #:
e.g. (XXX) XXX-XXXX ext XXXX
Primary Contact:
Additional Contact:
Primary Email:
Debtor Account
*
Amount Due:
*
Date of oldest outstanding invoice:
(MM/DD/YYYY)
Date of last payment:
(MM/DD/YYYY)
Product or service provided:
Do you have a credit application: yes  no
Do you have a personal guarantee? yes  no
Is the debt disputed? yes  no
If yes, indicate debtor's dispute?
Is any portion of the debt due to NSF checks? yes  no
If yes, was the NSF check(s) written on: COD  open account

By submitting the above account to The Andersen Group (TAG) for collection, we authorize TAG to start immediate collection of the past due balance. You, as our agent for this commercial claim, are authorized to accept payments, endorse checks, notes and other negotiable instruments. In the event it becomes necessary to forward the account to an attorney for legal review, we authorize you to select a Commercial Law League Attorney. We acknowledge commission will be charged on monies collected, whether paid direct to us or to TAG. Accounts are subject to regular fees after TAG acknowledges the claim

Debtor Documentation

To allow us to better protect your interests, we ask that you attach copies of credit applications, personal guarantees, statement of account and any other pertinent information.

Attach Below Or fax to (504)207-5700.

Debtor File #1:
Debtor File #2:
Debtor File #3:
Debtor File #4:
Debtor File #5:
Client Information
*
Your Company Name:
*
Placed By:
Address:
City:
State:
Zip:
Telephone:
e.g. (XXX) XXX-XXXX ext XXXX
Fax:
e.g. (XXX) XXX-XXXX ext XXXX
*
Email:
To email additional acknowledgement: