Retail Account Referral

The accounts listed on the form are assigned to the Bureau with power to settle, compromise, collect and adjust, or place with an attorney for legal action or collection. The Creditor assures that their firm has complied with the requirements of the Consumer Credit Protection Act of 1968 (Truth-In-Lending.)


E-mail Address: *
Name of Responsible Party
Social Security Number
Spouse
Phone
Street Address
Employment
Employers Address
Employers Phone
Whose Account
Amount Due
Delinquency Date
Last Pay Date
Last Date of Service
Account #
Check if Mail Returned
Comments, References, Employment of Spouse, etc.
Firm
By
Address
Phone
Date
* RequiredCreate Email Forms