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Consumer Placement Form

CLIENT INFORMATION

Name: ________________________________________________________

Address: ______________________________________________________

City: _______________________________  State: ______   Zip: ________

Phone: (   )_______________________     Fax: (   )____________________

DEBTOR INFORMATION:

Debtor: _________________________ ssn#: ______________________________

Spouse: _________________________ ssn#: ______________________________

Consumer Drivers Lic.#: State:______ ID#: ______________  Dob: ___________

Spouse Drivers Lic.#: State:______ ID#: ________________  Dob: ___________

Address: ____________________________________________________________

Previous Address: ____________________________________________________

Home Phone #: (   )______________ Work #:  (   )________________ Ext: ______

Debtor's Employer: ___________________________________________________

Employers Address: ______________________________ ph#: ________________

Spouse's Employer: ___________________________________________________

Employers Address: ______________________________ph#: ________________

Bank Info: ___________________________________________________________

Checking Account Number: __________________________

Type of Account: Savings (  ) Checking (  ) Other (  )

Account Info: __________________________________________________________

______________________________________________________________________

Other Creditors: _______________________ Account Number: _________________

Other Creditors: _______________________ Account Number: _________________


DEBT INFORMATION:

Amount Owed: $__________________ (including interest to date)

Interest Rate: _____________

Other Charges:

Discription of Added Charges:__________________________________

Total Owed: $__________________

Description Of What Debt Is For: ( ) Promissory Note ( ) Check ( ) Credit Card ( ) or Other: ______________________________________________________________

Reason given for non-payment: ____________________________________________

Is The Account Disputed: Yes:____  No: ____  If Yes Attach Details.

Has The Account Been With Another Collection Agency, Attorney, or Other Party For Collections:  Yes:____  No: ____  If Yes Attach Details.

Please Attach Co/Signer information (If Applicable)

Date of last payment: ______________________

Charge off date - Date They Defaulted - Loss date: __________________

Client account number or reference number: __________________________________

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


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