REQUEST FOR COLLECTIONS
Your Information
Date
*
Legal Name of your Comapny
*
Contact name and title
*
Address
*
City
*
State
*
Zip
*
Phone number
*
Fax number
Your e-mail
*
Debtor's Information
Debtor's company name
*
Debtor's contact name and title
*
Debtor's Address
*
Debtor's City
*
Debtor's State
*
Debtor's Zip
*
Debtor's phone number
*
Debtor's alternate phone number
*
Debtor's fax number
Debtor's e-mail
Principals of debtor's (Company 1)
Do you have a personal guarantee?
Yes
No
Principals of debtor's (Company 2)
Do you have a personal guarantee?
Yes
No
Do you have additional security?
*
Yes
No
List additonal security
Amount owed
*
List material supplied
*
List work performed
*
List any helpful information that could be used to recover this debt.
Do you have a written agreement with debtor?
*
Yes
No
Manna & Associates, LLC requires documentation to help us collect this debt. Please upload all documents in PDF.
This includes invoices, statements, agreements, cancelled checks, credit applications or any other documentation. You have up to 3 PDFs files to upload.
Upload Additional Documents
Upload a File
Cancel
of
Upload Additional Documents
Upload a File
Cancel
of
Upload Additional Documents
Upload a File
Cancel
of
Print Your Name
*
Print Your Title
*
Where Did you hear about us?
Your Email Address
*
I, the person named above, am authorized to order this service on behalf of the above named claimant. By clicking submit, I agree to allow Manna & Associates, LLC to collect this amount under the terms, rates and conditions as outlined at www.LiensAndCollections.com. I further agree that I will not deposit any payments made directly to me by the debtor, without prior approval from Manna & Associates, LLC. In addition, once I send this collection to Manna & Associates, LLC, I agree not have contact with the debtor. If I am contacted by the debtor, I will refer him to Manna & Associates, LLC.
If you would like to view our Rates and Terms,
PLEASE CLICK HERE
Submit
Should be Empty: