This is the first time I have submitted
a claim BC Services.
Your Account Number:
Debtor's
Name: First, Middle, Last
Debtor's Spouse
Name: First, Middle, Last
Debtor's Social
Security Number: (no dashes please)
Debtor's
Mailing Address:
City,
State, Zip:
Debtor's Phone: (555)555-5555
What type
Pre-collection account Healthcare billing account Full collection account
Principal
Amount:$
% (If N/A Enter 0)
Debtor's Employer
Date of Last Payment: mm/dd/yyyy
Date of Service:
mm/dd/yyyy
Date of Delinquency: mm/dd/yyyy
Mail Returned ? Yes
Account Disputed ? Yes
Other
helpful information about debtor: (For Example: references, nearest living relative,
parents' names25 CHARACTERS OR LESS )
Client
Number* : * For new clients, leave this field blank and fill in
information below.just fill in client number
and email address field below.
Name:
Street Address:
City, State, Zip:
Phone:
Email
Address:
By: (Name of authorized representative)
For value received, I hereby
assign and transfer to BC Services, Inc., a Colorado corporation, assignee
our account and claim against the debtor shown above in the amount shown
above of Principal plus interest, with full authority to take whatever
steps necessary to collect and satisfy the same. The undersigned warrants
that the account hereby assigned is a valid debt that has been itemized
for Principal and Interest, and is now fully due and owing to the undersigned
from the debtor named, that no payments have been made on the account
except as stated in said statement and that there is no just counterclaim
or offset against the same.
I AGREE
I DISAGREE
NOTE: If you are using Microsoft's Internet Explorer
browser, PLEASE be sure to double-check your required fields
so that you do not have to resubmit all fields!
