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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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