Debtor Company *

Principal *

Debtor Account Number *

Address

City

State

Zip

Phone

Fax

E-Mail Address *

Balance Due

Date of Last Payment

Oldest Invoice Date

Comments

Please add any supporting documents:

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In submitting the above debtor balance for collection, the following is agreed to:

Caine & Weiner Company, Inc. is authorized to commence collection action against the debtor. You are authorized to accept payment, deposit funds collected and to select an attorney, if necessary.

The handling of this debtor is governed by Caine & Weiner Company, Inc.'s standard fee schedule. It's understood Caine & Weiner Company, Inc. will not commence litigation without my authorization.

Client Name

Account Number

Attention

Address

City

State

Zip

Phone

Fax

E-Mail Address *

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