Affiliated Collections Contact Form

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Referral Form for Affiliated Collections

Client hereby submits this and future claim accounts to Affiliated Collections, LLC pursuant to the terms of the Engagement Agreement previously read, signed and mailed to Affiliated Collections, LLC.

Company:		City:
Contact:		State / Zip:
Address:		Phone:
Add. Cont.:		Fax:

Borrower(s)
Name:		Name:
Address:		Address:
Employment:		Employment:
Address:		Address:
Phone:		Phone:
S.S. #:		S.S. #:
Birth Date:		Birth Date:

Please Proceed with:
	Suit for Money Judgment	Suit for Replevin/Possession
	Suit for Foreclosure	Bankruptcy Representation

Account Detail:
Account #:		Interest Rate:
Loan Date:		Pay-off/Amount of Suit $:
Original Loan Amount:		Plus Interest From:

Special Instructions:

Security:

Yes No	I have read and signed the Engagement Agreement and have mailed it to Affiliated Collections, LLC.

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573-234-2813