Consumer Claim Submittal Form

Placing a consumer account with The Law Offices of Ross Gelfand, LLC is simple! Take a moment to complete the collection placement form below and we will immediately begin the collection process!
  Consumer Debtor Information
 
Debtor Name        SS# 

Address 1   

Address 2   

City   

State   

Zip Code

 E-mail 
Website 

Home Phone

Work Phone

Fax

Principle Amount Due

Interest Due

Total Balance Due

Interest Rate Per Annum

Debtor's Bank

Your File Number

Date of Last Payment  

Debtor's Attorney  


Debtor History - Please Check All That Apply

No Response Check Returned Disputed Mail Returned
Claims Inability To Pay Phone Disconnected 
Other


Please Include Any Additional Information Below in the Comments Box

 
  Creditor Information
Full Name
Title
Company Name
Address 1
Address 2
Phone
Fax
E-mail


Terms and Conditions

Please institute no proceedings, incur no expenses, make no compromises and/or grant extensions without written authorization.   All payments less your commissions must be remitted as received.  Collect interest wherever possible.  Claimant prefers all correspondence be conducted through our office.

This account is forwarded in accordance with the operative guides and receivers adopted by the commercial law league of America, to which we subscribe.  Failure to acknowledge claim, answer letters, or follow claimants instructions, will leave claimant free to recall this claim without payment of commissions to you.  Report promptly the possibility of collections.  If suit is advisable, state exactly what papers and cost you will require.  Charges and disbursements due on other claims must not be deducted from the amounts collected on this claim.

If these terms are not acceptable, please return immediately stating the reasons.  Please acknowledge receipt, stating whether the terms and conditions are satisfactory.


     

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