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FAX
FORM
Amount
of debt $____________Contact name____________________
Debtor
____________________________________________________
Street
address _______________________City___________________
State
___________ Country_______________ Zip_________________
Phone______________
Phone ______________Fax_______________
Other
ways to reach debtor____________________________________
Debtor
acct # ______________Sending backup? __________________
Written/oral
contract___________ Date debt incurred_______________
Description
of debt___________________________________________
Date
of last payment _____________Fees added
in________________
Helpful
information__________________________________________
Guarantor
__________________________________________________
Comments
_________________________________________________
Client
Authorization:
I do hereby authorize the collection firm of Phillips,
Harper & Harper to proceed with full collection
efforts on the above listed debtor on our behalf. This
account is subject to all parameters set forth in our
client agreement.
Date
signed ___________
Client________________________________
Authorized
by
_____________________________ Fax To 775-786-1528
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