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   BOTTOM LINE COLLECTION SERVICES
              
                                                                            

           
   
PLACEMENT TYPE:
 
 
debtor information:
Debtor Name:    
Address:    
City:    
State:    
Zip:    
     
Debtor Phone:  
Fax:  
E-Mail:  
     
Principal Amount Due:  
Account number used to identify Debtor:  
Date of Oldest Invoice:  
Date of Last Invoice:  
Brief note:    
CREDITOR INFORMATION (YOU)    
My name is:    
My company name is:  
My e-mail address is:  
My phone number is:  
    Example: 718-966-7776
       
 
 CLAIM PLACEMENT FORM