| In addition to completing this form, please send us by fax, email or regular mail, copies of all pertinent documents such as invoices, statements, returned checks, correspondence, etc. |
New Claim Submission Form
Contact Information
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| Your Name: |
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Your Company Name: |
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| Your Reference Number: |
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Your Telephone Number: |
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| Your Fax Number: |
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Your Email: |
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| Check here if you are an existing client |
Creditor
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| Name: |
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Florida Connection: |
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Debtor
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| Name: |
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Contact |
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Address 1:
Address 2: |
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City: |
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| State: |
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Zip Code: |
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| Primary Phone Number: |
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Secondary Phone Number: |
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Claim
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| Law List: |
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Does the FDCPA apply? |
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| Type of Claim: |
Other: |
Account Number: |
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| Principle Balance Due: |
$ |
Are we entitled to Attorney's Fee? |
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| Interest Rate: |
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Interest Date: |
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Comments
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| Please add any additional comments: |
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