Placement Form

YOUR INFORMATION:
All information in red is required.
Name of Your Firm
Address
City
State
Zip
Phone - -
Submitter's Name
Fax - -
E-Mail


DEBTOR INFORMATION:
Your Account #
Company Name
d/b/a
Owner/Principal/Contact
Other Contacts
Address
Address 2
City
State
Zip
Business Phone --
Residence Phone --
Fax --
E-Mail
Business Type Corporation / LLC
Partnership
Sole Proprietorship


CLAIM INFORMATION:
Amount of Debt
Date of Most Recent Purchase / /
Personal Guarantors
NSF Checks Yes No
Check #s Amounts:
Mail Returned Yes No
Disputed Yes No
Comments or Special Instructions (Please limit your comments to 800 characters or less.)

Open Immediately
Final Demand Expires on / /
(opening date)

Clicking "Send" signifies that you have read and agreed to the TERMS listed below.

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TERMS:

RAC: We assign the above-named account to you for collection on the final date specified above. If you are notified that payment has been received before the FREE DEMAND DATE, there will be no charge. If you do not hear from us before the above date, please proceed with collection of the above account on your established rules and rates.

The claim being referred is a commercial account and not consumer. The referral has been reviewed by the credit manager or manager of records. The debt is not time barred, is accurate and due.

You are authorized to accept payments, endorsed checks, notes, and other negotiable instruments, and to execute Proof of Claim Forms in Bankruptcies.

In the event it becomes necessary to tender the claim to attorneys for legal action, we authorize you, as our agent, to select counsel from any of the law lists approved by the American Bar Association or other medium available to you. Rosman Adjustment Corp. may retain, as compensation for its costs, all lawful sums collected over and above the principal balance of each claim.

Accounts that are withdrawn or settled by creditor after agency acknowledgement are subject to regular fees.

IN ORDER TO PROTECT YOUR INTERESTS, IT IS IMPERATIVE THAT WE KNOW THE PROPER LEGAL IDENTITY OF YOUR CUSTOMER.

Please fax or mail a copy of an itemized statement or invoices, copies of contracts, guarantees, the credit application, credit report, as well as original nsf checks and any other pertinent documentaiton relevant to the account.

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