Address of Account

Telephone Number of Account

Amount owed: $

First and Last Dates of Sales or Work Performed:

Total Charges for Entire Period:

Amount Paid, if any:

Balance Due: $

Type of Goods Sold or Nature of Work Performed:

Identify which of the following documents will be faxed or mailed to us:

Statement of Account Yes   No

Most recent check from the debtor Yes   No

Credit application Yes   No

Correspondence or other written documents Yes   No

Comments:

* Your Firm Name: (Required)

* Person to Contact: (Required)

* Phone Number: (Required)

* E-mail Address: (Required)