USA Claim Placement Form

Placing an account with Phillips, Harper & Harper is simple! Take a moment to complete the collection placement form below and we will immediately begin the collection process!

Debtor Information

Debtor Name

SSN

Address 1

Address 2

City

State

Country

Zip Code

Principle Amount Due

Interest Included

Rate of Interest

Total Amount Due

Debtor's Bank

Your File Number

Place of Employment

Employer's Address

Work Phone

Home Phone

Fax

E-mail

Mail Returned Yes No

Debtor History - Please Check All That Apply

No Response Check Returned Disputed Mail Returned
Claims Inability To Pay Phone Disconnected Other
Other

Please Include Any Additional Information Below in the Comments Box

Original Creditor Information

Original Creditor (if different from current creditor)

Original Account #

Original Date of Contract

Current Creditor Information

Date of Last Payment

Amount of Last Payment

Full Name
Title
Current Creditor Name

Address 1

Address 2

City State Country Zip Code

Phone
Fax
E-mail

Terms and Conditions

Please institute no proceedings, incur no expenses, make no compromises and/or grant extensions without written authorization. All payments less your commissions must be remitted as received. Collect interest wherever possible. Claimant prefers all correspondence be conducted through our office.

Failure to acknowledge claim, answer letters, or follow claimants instructions, will leave claimant free to recall this claim without payment of commissions to you. Report promptly the possibility of collections. If suit is advisable, state exactly what papers and cost you will require. Charges and disbursements due on other claims must not be deducted from the amounts collected on this claim.

If these terms are not acceptable, please return immediately stating the reasons. Please acknowledge receipt, stating whether the terms and conditions are satisfactory.

Please type the code in the black box into the box beneath it so we know this is a legitimate request.

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Letters are case sensitive.

Phillips, Harper & Harper, LLC

10475 Double R Blvd.

Reno, Nevada 89521

For Faster Delivery Use:

Post Office Box 11400

Reno, Nevada 89510-1400

Telephone: 775-322-2345

Fax: 775-786-1528

www.nevadacollectionattorney.com

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