Debtor

Name
Title
Organization
Street address
Address  (cont.)
City
State/Province
Zip/Postal  code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Creditor

Name
Title
Organization

Amount of Claim

Bank Information

Name

Creditors Compositions

INDIVIDUAL
PARTNERSHIP
CORPORATION - Inc. In the State of:

Instructions to the Attorney

Submit Suit Requirements  Investigate and Advise   File Suit Immediately    

Basis of Claim

Merchandise  Note         Service      Contract   

Our Experience

Broken Promises        Partial Payments       Stopped Payments       NSF Checks           
Dispute (See Remarks)  Unable to Contact      Pleads Poverty         

Enclosures

Statements  Invoice     Note(s)     NSF Checks
Contract    Suit Costs  

Remarks

Forwarded By:

Name
Title
Organization
Street address
Address  (cont.)
City
State/Province
Zip/Postal  code
Country
Work Phone
FAX
E-mail
URL