Debt form new - Statewide-Credit.com

"*" indicates required fields

Contact Email*

Client Number (SCS number) Must be a 4 digit numeric*

Directions for Debtor Name: Enter a Business Name for Commercial Debtors and Enter First Name, Last Name for Personal Debtors.
If you are entering a business, then choose "C' for debtor type field below in the form. If a personal name than choose blank.

Debtor Info

Debtor Name (Enter as First name Last name OR Business name) This is the party you wish to put into collections.*

Debtor Address 1

Debtor Address 2

City

State*

Zip

Soc Sec #

Home Phone

Cell Phone

Employer

Work Phone

Birthdate

Spouse Name

Spouse Birthdate

Spouse Sec Sec #

Spouse Work Phone

Debtor Occupation

Debtor Driver License #

Debtor Reference #

Part 2

Client Reference

Charge Off*

Guarantor/Patient Directions: Enter Contact Name for a Commercial account and Enter Guarantor/Patient for a Personal Account

Guarantor/Patient

Total Outstanding*

Date Incurred*

Attorney Name

Attorney Phone

Insurance

Debtor Type (Choose "C' for Commerical, "K" for Bad Check or blank for Personal)

Debtor Remarks (250 max characters)

Hidden

Orginal Maker

Finance Rate

Check Number

Check Bank Account Number

Last Finance Date

Finance Charge Assigned

Yes

Bank Name

Last Statement Date*

This is the date that will be used as the itemization date.

Balance at Last Statement*

Payoff amount as of the date of the last billing statement sent by You, the creditor.

Interest Since Last Statement*

Interest accrued from date of last billing statement sent by You, the creditor.

Fees Since Last Statement*

Fees charged from date of last billing statement sent by You, the creditor through the placement date. Does not include collection agency fees calculated for current placement.

Collection Agency Fees Since Last Statement*

Collection agency fees charged from date of last billing statement sent by You, the creditor through the placement date. Includes any fees that were accessed for prior placements that were not removed from the account before the current placement.

Payments Since Last Statement*

Payments posted from date of last billing statement sent by You, the creditor through the placement date.

Adjustments Since Last Statement*

Adjustments posted from date of last billing statement sent by You, the creditor through the placement date.

File

Drop files here or

Max. file size: 256 MB.

Name

This field is for validation purposes and should be left unchanged.