Today is September 22, 2018 Home About Us Contact Us
SINGLE CUSTOMER
IMMEDIATE COLLECTION ASSIGNMENT FORM
Complete and submit this form to assign your commercial collection account to Pacific Southwest Credit Association for immediate action.
 
Member Number:  Required  
 
1 - Please provide Debtor Information.
Debtor Name:  
Account No:  
Contact Name:  
Address:  
Address2:  
City:  
State:  
Zip Code:  
Country:  
Work Phone:  
Fax Number:  
Email Address:  
 
Debtor Entity:           
 
Please use the space below to give us the Name(s), Home Address(es) and Home Phone Numbers of any Owner, Partners, Corporate Officers:
 
 
 
 
 
 
 
 
Date of Last Charge:   (mm-dd-yyyy)  
Last Date Finance Charge or Interest Charge Added:   (mm-dd-yyyy)  
Date Last Payment Received:   (mm-dd-yyyy)  
 
Balance Due:   Required  
 
Which of the following will you be sending us to help collect this debt?
 
                                
                                
                                
 
Please add any comments you may have about this debt and/or debtor that would help us collect this balance for you:
 
 
Claim assigned on rates effective October 1, 1992. This account may be forwarded to attorneys for collection. Legal action will not be filed without authorization.
 
 
2 - Please provide information about the creditor.
 
Submitted By:  
Email Address: Required  
Phone Number:   (xxx-xxx-xxxx)