RAB - Account Placement Form

* denotes required fields

*Company Name:

*Amount:

Additional fees:

(Collection fees, interest, late fees, attorney fees, etc.)

*TOTAL TO COLLECT:

Legal Entity:
	Corporation		Partnership		Individual		Other

Name of Principals or Owner:
Name & Address of Debtor’s Bank:

BACKUP INFORMATION PROVIDED
	Invoices	Personal Guarantee	Credit Report	Credit Application
	Statements	Collection Notes	Original Checks	Additional Backup

Comments/Remarks: