A.) Briefly describe the type of accounts to be sent into collection:
          

B.) Anticipated volume to be placed:
          Dollar Amount:                   

          Number of Accounts:           

          Future Placement Frequency:

C.) Previous collection efforts on these accounts: (What has been done to collect on these accounts?)
          

D.) Average age of accounts; (how many days past due)?
          

E.) What information/backup do you have for the accounts? (Contracts, statements, original signed documents, etc.) What computer system is the information stored on?
          

F.) Contact Information
Name: