Consumer Placement Client Information Company Name Contact Address City State—Please choose an option—select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWyomingOther Zip Telephone Fax Email Consumer Placement Debtor Information Type of Claim—Please choose an option—please choose oneCommercialConsumerSubrogationIndividual Acount Number Name of Acount Responsible Party—Please choose an option—please choose oneIndividualCorporationBoth Contact Debtor Name Debtor's Social Security Spouse's Name Address City State—Please choose an option—select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWyomingOther Zip Debtor's Home Telephone Debtor's Work Telephone Basis of Claim—Please choose an option—collectionsServicesMerchandisePromissory NoteNSF Check —Please choose an option—subrogationAutomobileFraudContractOther Original Amount Due Current Amount Due Interest Amount Due Total Amount Due Do you have a signed contract ?YesNo Debtor HistoryMail ReturnedPhone DisconnectedDisputedCheck ReturnedInability to PayOther Additional Information Please Read Before Submitting:In submitting files for placement, the named client authorizes Your Collection Solution, Inc. to act as it's agent with respect to collections. Furthermore, client authorizes Your Collection Solution, Inc. to deposit all checks received into Your Collection Solution, Inc. Trust account. Your Collection Solution, Inc. will remit funds to client after deducting the agreed contingency fee. Disbursements will be paid biweekly when said monies have cleared our bank. In addition, client agrees to remit to Your Collection Solution, Inc. any monies received which were paid directly from the debtor less the agreed contingency fee. Captcha