TWENTY–FIRST CENTURY ASSOCIATES

Global Accounts Receivable Management

 

   800 Main St., Suite A Hackensack, NJ 07601-4851

   Tel. 201 678-1144 • Fax. 201 678-9088

 CONSUMER PLACEMENT  FORM

IMMEDIATE COLLECTION     Check for 10-DAY FREE DEMAND SERVICE

DEBTOR
DATE                     AMOUNT    
  
TRADE STYLE DBA
DEBTOR FAX
ADDRESS
CITY                                     STATE        ZIP
      
HOME PHONE
CELL PHONE
WORK PHONE
SOCIAL SECURITY #        
 

DRIVERS LICENSE #                   ISSUING STATE

BANK                          ADDRESS
ACCOUNT NUMBER
EMAIL ADDRESS

 

DOCUMENTS (CHECK BELOW AND FORWARD BY MAIL)
  ITEMIZED STATEMENT CREDIT APPLICATION RETURNED CHECK(S)
  INVOICE COPIES CREDIT REPORTS COPY OF DEBTOR'S CHECK(S)
  PROOF OF DELIVERY PROMISSORY NOTE OR
OTHER INSTRUMENT
PERTINENT CORRESPONDENCE
  BANK OTHER

 

REMARKS


You hereby authorize Twenty-First Century Associates, to endorse in your company's name, and to negotiate or to deposit in any bank account of Twenty-First Century Associates. any and all checks, notes, drafts, bills or exchange or other orders for the payment of money payable or endorsed to you which come into Twenty-First Century Associates. possession by virtue of its acting as your collection agent, and to remit the proceeds to you, less any fees which may be due whether or not such fees relate to the claim for which the funds were received.   Twenty-First Century Associates may use any funds collected to offset any open fees due Twenty-First Century Associates - for any account submitted to Twenty-First Century Associates for collection.

 

SIMPLIFIED RATES

COMMERCIAL RATES

CONSUMER RATES

MINIMUM COMMISSION

20% of Dollars Collected In House 

25% of Dollars Collected In House
0-$300.00 - 50% of Dollars Collected

30% Legal Collections

35% Legal Collections

Where necessary, Twenty-First Century Associates is authorized to forward this account to a bonded attorney.

CREDITOR

TELEPHONE NUMBER
REQUIRED
ADDRESS
CITY                                                STATE     ZIP
      
BY                                               TITLE
  
YOUR E-MAIL ADDRESS    REQUIRED
Twenty-First Century Associates will e-mail an acknowledgement.
   

 

 
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