CLAIMS LISTING FORM

 
CLIENT INFORMATION

The account listed below is submitted to MAREL ASSOCIATES
for collection.  The party authorizing placement of this account
agrees to the terms, conditions and fee schedule stated within
Marel's literature or claim acknowledgment sent to client by email.
Entity Name:* 
Address:*   
City:*  State:*  Zip Code:* 
Phone#:*                                   
Fax#:                                  
Authorized By:*  Title:*  
Email Address:* 
OK To Start Suit If Necessary: YES   NO
DEBTOR INFORMATION
Debtor:   
Contact: 
Address:  
City:  State:  Zip Code: 
Primary  Phone #:     
Alternate Phone #:  
Last 4 Digits Of SS#: 
Amount Due:  Date Debt  Incurred:  
Debtor Bank Name:   Client File No: 
Comments: