Joel Cohen


You should complete this form for each account that you want to turn over for collection.

    Name of Account

    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


    * Your Firm Name: (Required)

    * Person to Contact: (Required)

    * Phone Number: (Required)

    * E-mail Address: (Required)

Home | Firm Overview | Profile | Information
Claim Placement | For Clients Only | Frequently Asked Questions | Links | Map | Contact Us