Debtor Name
Address
City
State
Zip
Amount Owed
Invoice Date(s)

Bank Information

Name
Account Number
Is This A Bad Check?	YesNo
If Yes Please Furnish Check#, Bank Name, Amount, Date Returned, Reason Check was Returned
Check#
Bank
Reason for Return
Date

Indicate which of the following are available if needed:

Invoices?                                                        YesNo Statement indicating current balance due?    YesNo Credit Application?                                        YesNo Contracts or Purchase Orders?                       YesNo Copies of Checks?                                          YesNo Correspondence Concerning Claim?              YesNo