FOR IMMEDIATE COLLECTION

ATLANTA OFFICE  590 W. CROSSVILLE RD., STE. 104   ROSWELL, GA 30075

FAX: 770-993-2220

IMMEDIATE COLLECTION

DEBTOR:

ADDRESS:

CITY, STATE, ZIP:

DATE:                                                        AMOUNT $

OUR EXPERIENCE:

PARTY TO CONTACT:

TELEPHONE NUMBER:

DEBTOR'S BANK:                                                       

REMARKS & ENCLOSURES:

Please proceed with IMMEDIATE COLLECTION of the above account subject to your rate schedule.  We shall report promptly all payments & communications received from debtor.  The undersigned acknowledges & agrees to the TERMS & CONDITIONS given.

CREDITOR:

ADDRESS:

BY: