Consumer

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Consumer

Please submit basic information below to start the collection process. A service representative will get back with you for any additional information we may need.

Consumer Collection Placement Form

Client Information
*** Indicates required fields**
*Company Name:
Contact:
*Address:
*City:
*State:
Zip:
Telephone:
Fax:
*Email:


Debtor Information
Type of Claim:
Account Number:
Name of Account:
Responsible Party:
Contact:
*Debtor Name:
Debtor's Social Security:
Spouse's Name:
*Address:
*City:
*State:
Zip:
Debtor's Home Telephone:
Debtor's 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
	Check Returned Inability to Pay Other
Additional Information:

Please Read Before Submitting

In submitting files for placement, the named client authorizes Mid-South CRI to act as its agent with respect to collections. Furthermore, client authorizes Mid-South CRI to deposit all checks received into Mid-South CRI Trust account. Mid-South CRI will remit funds to client after deducting the agreed contingency fee. Disbursements will be paid monthly when said monies have cleared our bank. In addition, client agrees to remit to Mid-South CRI any monies received which were paid directly from the debtor less the agreed contingency fee.

Consumer Collection Placement Form

Send mail to info@midsouthcri.com with questions or comments about this web site. Copyright © 2008 Mid-South Collections, Recovery, & Investigations Last modified: 05/08/08

Send mail to info@midsouthcri.com with questions or comments about this web site.
Copyright © 2008 Mid-South Collections, Recovery, & Investigations
Last modified: 05/08/08