Your Name

Company

Position

Your Email (required)

Phone Number

Address

City

Province

Postal Code

Debtor

Ref #

Total Owed ($)

Interest Charged ($): $Cdn funds (inc. interest)

Reason for Placement
NSFBroken PromisesAvoidingBusiness SoldDisputed (Details attached)

Details of Debt (Invoice - dates, amounts, etc.):

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