Are You a New Client (required) YesNo
Your Name (required)
Client Number
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Sales Rep
Debtor (required)
Address (required)
Address
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State (required) ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
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Date of Last Invoice (required)
Amount of Debt, $ Amount (required)
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Comments
By emailing/faxing this account we are placing it for collection with Freeman, Miller, Gibson, LLC, and that we have agreed to all terms and conditions of their standard collection agreement. Upon placing this claim and upon receipt by FMG, we agree that we have retained their services to collect our past due claim. We agree to pay FMG, (% -tbd) for all fees recovered, either at the offices of FMG or direct payments sent to our office by the debtor company listed. We agree to notify FMG immediately upon receipt of all payments in whole or part, returned merchandise or any other returns, compromises or settlements received by our office. We understand that once this claim is placed that we are instructed to refer all calls to FMG for any purpose unless expressly notified in writing by FMG and to avoid any direct contact with the debtor once this account is placed. This agreement further authorizes FMG to negotiate checks received from the debtor companies into their trust account as required by law. FMG agrees to remit all recovered funds less any offsets for fees due FMG to the client. FMG will remit the net check minus the collection fee or any other fees for outstanding balances due FMG.
