Collection Submission Form

To CBK Services:
Please collect the account(s) listed below. They are in default , the balances shown are correct, just, unpaid, and we can furnish an itemization upon request. The accounts are not known to be disputed unless individually noted, nor are any accounts represented by an Attorney / third party unless so noted . None of these accounts have been or are now listed with other collectors or attorneys, to our knowledge. We agree to promptly report to you all payments made directly to us on these accounts. When any of these accounts cannot be collected by peaceable means and your investigation indicates legal action is advisable, you are hereby instructed to place such account(s) with your attorney or your agent's attorney for action. It is understood that your contingency fee for such legal action is 50% and you retain all interest to help cover legal expenses. It is further understood that you will cover all court costs, with the same to be withheld out of the first monies collected. No charges to us by you if no collection is made. These claims are in compliance with Federal Truth and Lending regulations. Required items are noted with **

From:
Client Number:
Person Submitting Account
Phone:
Email Address:
Your Account Number
Joint Account:
Collection:

Responsible Party's Name**:

Responsible Party's SSN:
Spouse's Name:
Spouse's SSN:
Address, City, State, & Zip::
Mail Returned?:



Phone Number: :
Employer:
Employer's Phone:
Date of Last Charge**:
Date Last Payment
Principle Due:
Interest Due:
Total Due**:
Is this Account Disputed?:
Comments:
 

 

 
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