Collection Agency | Consumer Placement

Alternative Receivables Solutions, Inc.

Client Information
* - Indicates required fields
*Company Name:
Contact:
Address:
City:
State:
Zip:
Telephone:
Fax:
Email:
Consumer Placement
Debtor Information
Type of Claim:
Account Number:
*Name on Account:
Responsible Party:
Contact:
*Debtor Name:
Debtor Social Security Number:
Debtor Spouse:
Debtor Address:
City:
State:
Zip:
*Debtor Home Telephone:
Debtor Work Telephone:
Basis of Claim:
Original Amount Due:
Current Amount Due:
Interest Amount Due:
Total Amount Due:
Do you have a signed contract?	Yes No
Debtor History:	Mail Returned Phone Disconnected Disputed
Additional Information?
Please Read Before Submitting
In submitting files for placement, the named client authorizes ARS, Inc. to act as it's agent with respect to collections. Furthermore, client authorizes ARS, Inc. to deposit all checks received into ARS, Inc. Trust account. ARS, Inc. will remit funds to client after deducting the agreed contingency fee. Disbursements will be paid monthly and by the 15th of each month when said monies have cleared our bank. In addition, client agrees to remit to ARS, Inc. any monies received which were paid directly from the debtor less the agreed contingency fee.

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