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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)