Directions: Fax Montgomery & Meyers, a National Collection Service Company the following information to begin the commercial asset and liability investigation immediately.  Fill out as much information as you may have on the debtor company or you can fill out the debtor name, sign the form and attach any copies of invoices, statements, credit applications, trade references, check copies or any other material or information the field investigators and commercial collection investigators may use to begin the process.  We will immediately begin the commercial financial asset and liability investigation and request any additional information as circumstance warrant and develop.  An investigator will be in touch within the first 24 – 48 hours to discuss the preliminary investigation and your claim. Please remember to refer all debtor calls back to Montgomery & Meyers.

Debtor Company Contact Name:
Debtor Company Name:
Debtor Company Address:
Debtor Company Phone No:
Debtor Company Fax No:
Date of Last Payment or Service:
Debtor Company Website:
Debtor Company Email:
Signed Contracts/Invoices/Credit Application/Trade References
(Please circle those items from the list above that you have or can provide if necessary if they were not sent with the placement)
Amount Due:
Collection/Legal Expenses:

*** We hereby agree by faxing this account that we are placing it for collection with Montgomery & Meyers, that we have agreed to all terms and conditions of their standard collection agreement. Upon placing this claim and upon receipt by M&M, we agree that we have retained their services to collect our past due claim. We agree to pay M&M, (% -tbd) for all fees recovered, either at the offices of M&M or direct payments sent to our office by the debtor company listed. We agree to notify M&M immediately upon receipt of all payments in whole or part, returned merchandise or any other returns, compromises or settlements received by our office. We understand that once this claim is placed that we are instructed to refer all calls to M&M for any purpose unless expressly notified in writing by M&M /NCSC and to avoid any direct contact with the debtor once this account is placed. This agreement further authorizes M&M to negotiate checks received from the debtor companies into their trust account as required by law. M&M agrees to remit all recovered funds less any offsets for fees due M&M by the client within 30 days of recovery. M&M will remit the net check minus the collection fee or any other fees for outstanding balances due M&M /NCSC. M&M will also provide a report with all remittances outlining recoveries, fees, and balances due. M&M retains the right to bill the client the agreed contingency fee for any accounts closed, compromised, settled  discovery or any account interfered by the client after M&M has received the claim.

All cancellations must be in writing and M&M chas (90) days from the date of cancellation to make a final determination on the status of the file and reserves the right to return or bill the client for work done on file. M&M may also continue to work the file under the original placement agreement depending on the merits of the case status and pending actions on the file at the time of the cancellation request.

Client Company Name and Address/Contact information:
Phone No:
Fax No:
Enter Security Code *:


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