Account Placement Form – Winters & Williams

Account Placement Form

Debtor 1 Information

Name of Debtor

Address

Address Line 1

Address Line 2

City

State

Zip Code

Full Balance of Account

Phone

Fax

Comments (Please Select One)

Date of Open Invoice

Client Reference #

NSF Check #

Debtor 2 Information

Name of Debtor 2

Address

Address Line 1

Address Line 2

City

State

Zip Code

Full Balance of Account

Phone

Fax

Comments (Please Select One)

Date of Open Invoice

Client Reference #

NSF Check #

Client/Creditor Information

Client/Creditor

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

Fax

Authorized By

First

Last

Email