NACM Tampa Inc. PO Box 22827 Tampa FL 33622 Ph: 800.329.6226 813.964.9814 F: 813.864.9864
Collection CLAIM PLACEMENT FORM
Only Commercial Claims Accepted
PLACE AN ACCOUNT FOR COLLECTION IMMEDIATE ATTORNEY REFERRAL * AMOUNT DUE $
DEBTOR INFORMATION
Entities' Full Legal Name: *   Trade Style (d/b/a):   Business Type: * LLC     LLP     Sole Proprietorship Partnership     Corporation     sCorp     Other   Physical Street Address: * City:*     State: * Zip +4: *     Mailing Address: (if different from above) City:   State: Zip +4:   Contact Person: * Second contact person:   Telephone number: * Telephone number:   Cell Phone number: Cell Phone number:   Fax number: Debtor Account #:   Email address: Email address:
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CLAIM PLACEMENT INFORMATION PACKAGE MUST INCLUDE ITEMS IN THE CHECKED BOXES. IF A REQUIRED ITEM IS UNAVAILABLE, PLEASE UNCHECK THE APPROPRIATE BOX AND SPECIFY WHY THAT ITEM IS UNAVAILABLE.
	* Credit Application * Any Signed Guarantees * Invoices * Any Contracts * Statement of Account * Provisions for Attorney Fees/       Collection Fees NSF Checks Correspondence Credit References
PLEASE EMAIL or FAX THE CREDIT APPLICATION and all supporting documents to: srodolf@nacmtampa.com Fax (813) 864-9864
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Comments:
Is this claim disputed? Yes  No If yes, nature of dispute:
CREDITOR INFORMATION
Company:*
Contact:*
Telephone number:*
Member Number:
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Click here to view the Rate Schedule set forth by NACM Tampa.