Name of Company:   Client Number:

Debt Coordinator: (the person who will receive correspondence, checks and reports from Accurate Information Services).

Mailing Address:  

Phone: Fax: E-mail:

Nature of Debt: (book account, judgment, promissory note, ect...)

Debtor's Information

Name: Amount owed:

Address:

Phone: Days past due:

(Rhode Island has no Licensing for collections)

Any information provided in this form will be used to collect any debt lawfully due to the debtor and for no other reason.