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Commercial Placement Form

CLIENT INFORMATION

Name: ________________________________ Contact: _______________

Address: ______________________________________________________

City: _______________________________  State: ______   Zip: ________

Phone: (   )_______________________     Fax: (   )____________________

DEBTOR INFORMATION

Name of Debtor: ______________________________________________

Last Known Address: __________________________________________

Last Known Phone #: __________________ Fax #: __________________

Business Entity: ( ) Proprietorship ( ) Partnership ( ) Corporation

If Proprietorship, doing business as:________________________________

If Partnership, name of partner(s): _________________________________

If Corporation, name of all known shareholder(s) and officer(s):

__________________________________________________________________

__________________________________________________________________

Any Personal Guarantor: Yes______ No_______

If so, name of Guarantor (please attach copies of Guaranty):

Principal amount owed: $_____________

Accrued Interest: $_____________

Interest Rate: (other than legal rate of 10%): ___________

Total Owed: $_____________

Name of Bank (including Branch): ____________________________________

Account #: __________________________

Address of any other business location: ________________________________

Date customer attempted to cancel the contract: _________________________

Was the customer delinquent at the time of the attempted cancellation? _______

Conditions, if any, under which you are willing to continue to do business with the customer?

__________________________________________________________________

__________________________________________________________________

Settlement authority (if any): ____________ i.e. percentage or dollar amount

FAX TO: 972-272-3111  MAKE SURE YOU CONFIRM RECIEPT OF FAX AT 972-272-4141


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