Online Placement

Immediate Action                                   Final (Free) Demand ** 

Creditor Information:

NACM Member:  Yes    Member Number      No

Company: *
Address: *
City/State/Zip: *
Authorized by: *
Phone: *
Fax:
E-mail:
Debtor Name: *
Debtor Contact:
Corporation     Sole Proprietor     Partnership    Other
Personal Guaranty:   yes no
Guarantor's Name(s):
Debtor Account Number:
Debtor Physical Address:
City/State/Zip:
Debtor Mailing Address: *
City/State/Zip: *
Debtor's Phone:          Debtor's Fax: 
Principal Balance Due: $*
Interest: $
Collection Fees: $***
Total Due: $*

Attach File/Supporting Documentation:

1)  2) 

3)  4) 

5)  6) 

Comments/Instructions:

    

 

*Indicates required field

*By submitting this claim you agree to the terms and conditions as set forth on our rates page unless other arrangements have been made.

**Claims placed in Final (Free) Demand automatically go into regular collection after the 10 day free demand expires.  Claims withdrawn during the 10 day free demand period are subject to full fees on the amount placed.

***Creditor must have signed agreement with customer to include collection fees.  NACM commissions are due on all amounts collected, including interest, collection fees, etc.  Collection fees are statutory and may be limited by local statute.