Account Placement Form

DEBTOR INFORMATION

Please check all that will be submitted

Please read the following carefully

I authorize United Business Strategies LLC (UBS) to commence collection action against the above debtor. UBS is also authorized to accept the debtor's payment (s) and deposit the payment (s) into their trust account on my company's behalf.

Client Status

Company Name

Contact Name

Company Address

State

Country

ZIP

Phone

Ext.

Fax

E-mail Address

Debtor Company Name

Owner

Address

City

State

Country

Phone

Phone (Alt)

Fax

Email Address

Debtor Account Number

Type of Company

Outstanding Balance

Date of Last Sale

Date of Last Payment

Credit Application

Personal Guaranty

Invoice Copies with POD

NSF Check Copies

Other

Other

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