Your Company Information

*Your Company Name:

*Your Name:

Address:

City:

*Daytime Telephone:

Evening Telephone:

Fax Number:

*E-mail:

Your Debtor Information

*Debtor Company Name:

Debtor Contact Name:

*Address:

*City:

Daytime Telephone:

Evening Telephone:

Fax Number:

E-mail:

*Amount Owed:

Pertinent Information

Date Debt Incurred:

Tax ID or SS Number:

Is There A Signed Contract?

Is There Back-up, Such As Invoices?

I Have Read FITEC's Terms of Service:

Is This A Judgment?

Date of Judgment:

Product or Service Provided:

Reason For Non-Payment:

Additional Information:

  Confirm: YES << You must select "YES" to submit this form, whereas you agree to the following: This form authorizes FITEC to begin immediate collection action against the Debtor named above. Any and all payments remitted directly to you after the date entered above shall be deemed as having been collected by us, and shall incur the full applicable collection fee. If no collection is made, there will be absolutely no charge for our services. We also agree to pay client for any monies sent to us by the debtor within 30 days of receipt of payment. All collection activities will be undertaken in accordance with all state and federal collection laws. All rates are negotiable based on age and volume of accounts.

Confirmation will be faxed or e-mailed within 24 hours.