DEBTOR INFORMATION
Debtor company's name:
Debtor contact name:
Debtor company's street address:
Debtor company's city, state and zip code:
Debtor company's telephone number:
Debtor company's fax number:
Date(s) and amount(s) of past due invoice(s):
Terms of sale:
Today's date:
TOTAL DEBT AMOUNT AS OF TODAY'S DATE: $

Please feel free to offer your comments below:

By clicking the "Submit Collection" button below you agree to the following: this form authorizes DPL Associates, Ltd. (hereinafter DPL) to begin immediate collection action against the Debtor named above. Any and all payments remitted directly or indirectly to you, your employs, agents, or assigns by Debtor, Debtor's employs, agents, assigns, benefactors or other third parties as full or partial payment for debts submitted to DPL for collection after the date entered above shall be deemed as as having been collected by DPL, and shall incur the full applicable collection fee. If no collection is made, there will be absolutely no charge for DPL's services. Collection fees for full or partial collections shall be made payable to DPL and are due upon your receipt of collected funds. Should DPL deem it necessary to to employ an attorney to collect its fee from you, the Creditor, you understand and agree to be responsible for DPL's attorney's fees, court costs, and related expenses. If Debtor returns and you accept merchandise and or services in lieu of full or partial payment after the date entered above, DPL will be entitled to a fee equal to 15% of the contracted price of the merchandise returned or the services rendered. No attorney will be employed nor lawsuit begun without your consent.All collection activities will be undertaken in accordance with all applicable state and federal collection laws.