Date: -- mm/dd/yy

Please provide your company information:

Your Name/Title
Your Company Name
Phone
Fax
E-mail

Please provide debtor account information:

Debtor's Company Name
Debtor's Contact Name
Debtor's Address
City
State/Province
Zip/Postal Code
Country
Phone
Fax
E-mail

Total Amount Owed $:

Your Reference/Account #:

CLAIM INFORMATION: Please list all outstanding invoice numbers, dates and amounts, last payment date, or any other pertinent information.

JWS, acting as client’s agent, is authorized to collect the account (s) according to federal and industry guidelines.  JWS is hereby authorized to accept payments, to endorse checks, money orders or drafts for deposit into trust and to remit net proceeds.  Fees will be charged on all accounts collected, settled, paid direct, credits issued or by return of merchandise from the date of placement.  Clients may cancel any account placed with a 30 day written notification.  JWS standard collection rate will also apply on any accounts withdrawn.  For debtors who resist all normal collection efforts and who offer a potential for legal recourse, client authorizes JWS to forward the claim (s) to an attorney for legal action at the client’s direction and expense.