U.S. Domestic Claim Placement Form

Placing an account with Sierra Nevada Adjustment Group is simple! Take a moment to complete the collection placement form below and we will immediately begin the collection process!

Debtor Information

Debtor Name

SSN

Debtor Contact	Web Address
Address 1	Address 2

City

State

Country

Zip Code

Principle Amount Due (Us Dollars Only)

Interest Included

Rate of Interest

Date of Last Payment	Amount of Last Payment

Total Amount Due (US Dollars Only)

Debtor's Bank

Your File Number

Place of Employment

Employer's Address

Work Phone

Home Phone

Fax

E-mail

Mail Returned Yes No

Debtor History - Please Check All That Apply

No Response Check Returned Disputed Mail Returned
Claims Inability To Pay Phone Disconnected
Other

Please Include Any Additional Information Below in the Comments Box

Original Creditor Information

Original Creditor (if different from current creditor)

Original Account #

Original Date of Contract

Current Creditor Information

Please List Sales Executive's Name or How Referred To Our Agency

Full Name
Title
Current Creditor Name

Address 1

Address 2

City State Country Zip Code

Phone
Fax
E-mail

Terms and Conditions

Please institute no proceedings, incur no expenses, make no compromises and/or grant extensions without written authorization. All payments less your commissions must be remitted as received. Collect interest wherever possible. Claimant prefers all correspondence be conducted through our office.

Failure to acknowledge claim, answer letters, or follow claimants instructions, will leave claimant free to recall this claim without payment of commissions to you. Report promptly the possibility of collections. If suit is advisable, state exactly what papers and cost you will require. Charges and disbursements due on other claims must not be deducted from the amounts collected on this claim.

If these terms are not acceptable, please return immediately stating the reasons. Please acknowledge receipt, stating whether the terms and conditions are satisfactory.

If you haven't done so already, please review our client agreement, sign and fax to 775-786-1528

Sierra Nevada Adjustment Group

West Coast Office

10475 Double R Blvd.

Reno, Nevada 89521

Telephone: 775-786-0121 ext 179

Fax: 775-786-1528

Sierra Nevada Adjustment Group

East Coast Office

72 Marsh Oak Drive

Brunswick, Georgia 31525

Telephone: 912-261-9133

Fax: 912-261-9219

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