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Commercial Claim

Consumer Claim

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Use this form to submit a Commercial Collection Claim via email.  An ACL representative will contact you shortly to confirm your claim and gather any additional information we may need.

Debtor Information:

Name
Title
Organization
Account #
Address Line 1
Address Line 2

City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
Claim Amount

If you need to send us any of the additional items listed below, please indicate here:

Itemized Statement of Account
Credit Application
Invoices
Copy of Bad Check (NSF checks only)
Copy of Debtor Check (to assist in locating debtor's bank account)

Debtor's Social Security #:

Additional Comments:



Client Information:

Name
Title
Organization
Address Line 1
Address Line 2
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
e-mail

Claim Submitted By (leave blank if same as client name):


 

 

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