- Placement Form

Your Company Section

Please Complete

Your Company Name *

Your Complete Name *

First Last

Your Company Telephone Number *

### - ### - ####

Telephone Extension

Your Company Fax Number

### - ### - ####

Your Company Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Your Company Email *

Debtor Section

Please Complete

Debtor Company Name *

Debtor Complete Name *

First Last

Debtor Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Debtor Phone Number(s)

If multiple telephone numbers place a comma between each trlephone number

Debtor Email

Principal Balance Due

Oldest Invoice Date

MM / DD / YYYY

Most Recent Invoice Date

MM / DD / YYYY

Do You Have a Credit Application?

Do You Have a Personal Guarantee?

Do you have a signed contract?

Are there any returned checks involved?

What has the debtor told you thus far about paying?

Terms and Conditions

I, the forwarder/creditor have reviewed the books and records that support this claim and do hereby warrant and represent that this is a valid claim. It is currently due and owed to the creditor by the debtor on a open account receivable. I have not added attorney fees or collection costs to the balance. If interest is added, I have a contract signed by the debtor that allows for the interest that is charged. I am not aware of any bankruptcy filings. I understand that placement of this claim does not mean that it has been accepted by Goldman & Warshaw, P.C. Acceptance of this claim will be evidenced by letter from Goldman & Warshaw, P.C. after the claim has been reviewed by an attorney. If a lawsuit is requested, I understand that I am responsible for all court costs. Goldman & Warshaw, P.C. will provide collection services including skip tracing, asset location, and litigation on a contingency fee basis. However, any Counter Claim, 3rd party Complaint, Appeal or deposition is not part of the contingency fee arrangement.

I Agree with the above terms and conditions *

yes