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	10/07/08 00:32 am

CLAIM FORM

All fees are strictly contingent upon collection.

* denotes optional field

CLIENT INFORMATION

Company Name:

Contact Name:

Address:

City:

State:

Zip Code:

Country:

Phone 1:

* Phone 2:

* E-Mail:

Fax:

* Client ID # :

DEBTOR INFORMATION

Name of Account:

* Responsible Owner/Officer/Party:

Address:

City:

State:

Zip Code:

Country:

Phone 1:

Phone 2:

* E-Mail:

* Fax:

Account # :

*Balance Due:

* Exchange Rate at
Time of Transaction:

* U.S. Dollars:

Date of Last Transaction:

DOCUMENTATION TO FOLLOW: (Copies Only Please, No Originals)

Will Receive By:
Mail Fax

Invoice(s)	Original Contract
Credit Application	COD NSF Check
Itemized Statement	Open Account NSF Check

Additional Information:

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