Claim Form
By Completing and submiting the form below, I/we the claimant(s) do hereby pass the debtor for your collection services.
Date
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Debtors Name (*)
Debtors Address
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Telephone
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Brief Desicription of Goods or Services
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Date of Invoice Issues
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Total Outstanding
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Total O/S plus 17.5% CDI Costs
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Client Address
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Client Name
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