Placement | Cosmopolitan Service

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New Claim Placement Form

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Client Name (Your Company Name)

Client Address:

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

I provide Cosmopolitan Service Corporation authority to immediately proceed on our behalf to recover the following receivable. I accept the fee schedule pertinent to the terms and conditions.

Debtor Firm Name

Debtor Firm Address

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Responsible Party

Responsible Party Title

Responsible Party Phone

Amount Due ($)

Interest

Service Charge (if any)

Total Claim

Date of Last Invoice

Debtor Email

Debtor Bank Name (if available)

Collection Type

At the discretion of CSC

Ten Day Demand

Forwarding Service

Please provide us with any of the following documentation you may have available. You may also submit this documentation at a later time via email.

Itemized Statement, Invoice Copies

Upload File

Credit Application

Upload File

Pertinent Correspondence

Upload File

Origional Contract

Upload File

Origional NSF Check(s)

Upload File

Notes, Drafts and/or Personal Guarantees

Upload File

I have reviewed the Terms and Conditions of services and have elected to proceed as indicated above, the rate structure is accepted and the Terms and Conditions of placement are acknowledged.View terms and conditions of services

Looking forward to an early acknowledgment and report. I remain, (your signature)

Thank you for placing your claim with us. A representative will reach out shortly.