PLACE ACCOUNT

Client Information (Creditor)

Debtor Information

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By submitting an account for collections using this form you hereby authorize RAB, Inc. to begin IMMEDIATE collection activities. Please report all payments promptly. Should the debtor attempt to contact you directly you hereby agree NOT to communicate with the debtor and will refer them back to RAB, Inc. Cancelling/Withdrawing an account submitted for collections will result in full commission to be due.

Thank You For Your Continued Trust