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Fax
Form
Amount
of debt $____________Contact
name____________________
Debtor
____________________________________________________
Street
address
_______________________City___________________
State
___________
Country_______________
Zip_________________
Phone______________
Phone
______________Fax_______________
Other
ways to reach
debtor____________________________________
Debtor
acct #
______________Sending
backup? __________________
Written/oral
contract___________ Date
debt incurred_______________
Description
of
debt___________________________________________
Date
of last payment
_____________Fees added
in________________
Helpful
information__________________________________________
Guarantor
__________________________________________________
Comments
_________________________________________________
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Client
Authorization:
I do hereby authorize the
collection firm of Sierra
Nevada Adjustment Group to
proceed with full collection
efforts on the above listed
debtor on our behalf. This
account is subject to all
parameters set forth in our
client agreement. |
Date
signed ___________
Client________________________________
Authorized
by _____________________________
Fax To 775-786-1528
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