Claim Placement Form**
  Terms and Conditions
By Submitting this form, you as a representative of the creditor company and the creditor company (hereinafter called creditor) agree that all actions taken by Creditors Interchange (hereinafter called CI) shall be in accordance with the TERMS AND CONDITIONS.

1. Creditor refers the specified account to CI for collection and CI is authorized to proceed at once to collect the specified amount.

2. Creditor hereby warrants that all claims forwarded to CI will be valid and legally enforceable debts, and that the Creditor will, both before and after forwarding said claims, comply with all applicable federal, state and local laws thereto. To the best of the Creditor's knowledge, claims forwarded to CI are not discharged debts in bankruptcy and Creditor acknowledges that all accounts being placed with CI reflect the name or entity under contract with Creditor.

3. Creditor has notified Debtor in writing of all additional fees, interest, late charges or collection fees that may be added to the original amount due and Debtor has agreed in writing to the imposition of such charges prior to the claim being turned over to CI. By including all such fees and charges in the amount of the claim turned over to CI, Creditor is certifying that it has debtor's written agreement to the inclusion of such charges.

4. Commission will be charged on amounts collected, paid direct or settled by return of merchandise. CI, as Creditor's agent, is authorized to accept payments and to endorse checks, notes, money orders or drafts for deposit; the net proceeds of which CI is to remit to Creditor. All money received from collections is deposited in a "Trust Fund Account". Remittances will be made on collections from CI by the 15th of each month for the previous month's collections. Price arrangement for the above account will be in accordance with the "Schedule of Fees".

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  Client / Creditor Information
Contact Person*
Email*
Company Name*
Phone 1 + EXT*
Street Address*
Phone 2 + EXT
City*
 State*
 Zip Code*
Fax + EXT
Account Number
 Client Number (if a returning client)
Placement Type:
1st Placement 2nd Placement Judgements
 
Debtor Information
Debtor Company Name*
Contact Person
Address 1*
Phone
Address 2
Fax
City*
 State*
 Zip Code*
Email 
 
 
Debt Information
Outstanding Balance*
 
Date of Oldest Outstanding Invoice
Date of Last Payment
Date of Most Recent Outstanding Invoice
Last Amount Paid
 
 
Client Documentation
Please indicate all items to be forwarded to Creditors Interchange:
Detailed Invoices
Weigh Bills
Contracts
Letters of Guarantee
Copies of NSF Checks
Final Demand Notices
Customer Confirmation/Promissory Notes
Other (specify)
 
Document Delivery (please check the delivery method):
Express Mail
USPS
Electronically
Fax (716-614-7608)
 
Additional Information / Comments:
 
 
 
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