888-378-8100 - Your Judgment Soluition

Commercial Judgment Enforcement
Commercial Debt Collection


Client Information
* - Indicates required fields
*Company Name:
Contact:
*Address:
*City:
*State:
Zip:
Telephone:
Fax:
*Email:

Consumer Placement
Debtor Information
Type of Claim:
Account Number:
Name of Account:
Responsible Party:
Contact:
*Debtor Name:
Debtor's Social Security:
Spouse's Name:
*Address:
*City:
*State:
Zip:
Debtor's Home Telephone:
Debtor's Work Telephone:
Basis of Claim:
Original Amount Due:
Current Amount Due:
Interest Amount Due:
Total Amount Due:
Do you have a signed contract ?	Yes No
Debtor History :	Mail Returned Phone Disconnected Disputed
	Check Returned Inability to Pay Other
Additional Information:

Please Read Before Submitting
In submitting files for placement, the named client authorizes Your Collection Solution, Inc. to act as it's agent with respect to collections. Furthermore, client authorizes Your Collection Solution, Inc. to deposit all checks received into Your Collection Solution, Inc. Trust account. Your Collection Solution, Inc. will remit funds to client after deducting the agreed contingency fee. Disbursements will be paid biweekly when said monies have cleared our bank. In addition, client agrees to remit to Your Collection Solution, Inc. any monies received which were paid directly from the debtor less the agreed contingency fee.

Commercial Judgment Enforcement Commercial Debt Collection

Toll Free 888-378-8100 - Broward County 954-577-7700 - Fax 954-424-0500