A wholly-owned subsidiary of the Midland Chamber of Commerce



Client # Client Name Phone

Client Address City State Zip

Authorized by Title Date

□ Please call me to discuss our collection problems.

DEBTOR INFORMATION:

Acct. # Date of Service Date Last Pay Amount $

Full Name S/S # DOB

Complete Address (include Zip Code)

Phone ( ) Work Phone # Employer

Resp. Party (if under 18) S/S # DOB

Spouse Name S/S # Work #

Date of Birth Employer Mail Returned

Additional Information (relatives, references, etc.)

DEBTOR INFORMATION:

Acct. # Date of Service Date Last Pay Amount $

Full Name S/S # DOB

Complete Address (include Zip Code)

Phone ( ) Work Phone # Employer

Resp. Party (if under 18) S/S # DOB

Spouse Name S/S # Work #

Date of Birth Employer Mail Returned

Additional Information (relatives, references, etc.)

DEBTOR INFORMATION:

Acct. # Date of Service Date Last Pay Amount $

Full Name S/S # DOB

Complete Address (include Zip Code)

Phone ( ) Work Phone # Employer

Resp. Party (if under 18) S/S # DOB

Spouse Name S/S # Work #

Date of Birth Employer Mail Returned

Additional Information (relatives, references, etc.)

DEBTOR INFORMATION:

Acct. # Date of Service Date Last Pay Amount $

Full Name S/S # DOB

Complete Address (include Zip Code)

Phone ( ) Work Phone # Employer

Resp. Party (if under 18) S/S # DOB

Spouse Name S/S # Work #

Date of Birth Employer Mail Returned

Additional Information (relatives, references, etc.)

• There are statutory limits on the length of time you may report this debt to a credit bureau.

• The creditor further agrees to inform the undersigned collection agency upon its receipt of any information which would render the account information contained herein more complete, accurate or obsolete including but not limited to, notice of a consumer bankruptcy filing

• Collection agencies are prohibited by law from pursuing collection of late fee’s, interest, etc. without a copy of a signed contract between debtor and client agreeing to the same. Please submit itemized statement if available.

• IMPORTANT NOTICE: To ensure proper credit reporting information is provided to the National Credit Reporting Agencies by CBM, it is imperative that the creditor report direct payments to CBM upon receipt. This may be done by telephone, fax, or mail whichever is more convenient.

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CBM Services, Inc.

P.O. Box 551 Midland, Michigan 48640 ~ (989) 631-0104 ~ 1-800-968-2733 ~ Fax (989) 631-0705

❑ Precollect

❑ Standard

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