Small Business Services - Single Placement Worksheet/Placement Form

Client Name:
Client Phone:
Contact Name:
Client Fax:
Client E-Mail:
Client Address:
City:
State:
Zip:
Debtor Name:
Contact Name:
Debtor Address:
City
State
Zip
Debtor Home Phone:
Debtor Business Phone:
Social Security #:
Type of Debt:
Fax #:
Amount Due:$
Last Pay: $
Case/File/Invoice#:
Nature of Debt:
Credit Card #:
Expiration Date:
Type:


This document authorizes 1st NationWide to place a $24.95 charge on the above-listed credit card as a File Initiation fee. Upon collection 1st NationWide will retain a standard collection fee of 30 (Thirty)% of all monies collected on behalf of client. Funds collected between the 1st and 15th of every month will be remitted on the 15th of the following month. Funds collected between the 16th and the 31st are remitted by the end of the following month. 1st NationWide will adhere to the Federal Fair Debt Practices Act as well as all local and state laws. We will bill you for the commissions due in the event of a direct payment to you. Further, any commissions not paid within 15 days of our billing, can be charged to the above-listed credit card.

Client asserts that the debtor information given above is true and correct. Client assumes all responsibility for the validity of the information reported to the credit reporting agencies. You are assigning 1st NationWide the right to communicate with the debtor on your behalf. We have no vested interest in the debt. To cancel this agreement you must notify this office in writing and give 120-day notice.

A discovery fee of 1/2 the commission rate will apply for locating payments and for effecting merchandise or equipment returns for settlements of accounts. 1st NationWide Collection Agency, Inc. is not liable for claims becoming barred by the Statue of Limitations. A faxed or E-mail signature will be accepted to be the same as the original signature by both parties.

We and 1st NationWide Collection Agency, Inc. by virtue of us assigning and them accepting our accounts for collection, agree to hold each other harmless from any and all damages, attorneys fees and costs for any errors, negligence or wrongful acts committed by either involving an account assigned to them by us. WE AUTHORIZE YOU TO ENDORSE CHECKS AND MONEY ORDERS.

E-mail
FAX: 1-888-847-2595
Signed CALL: 1-888-847-2499


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