New Business Placement Form

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PLACEMENT OF NEW BUSINESS - FOR CLIENTS ONLY
TO BECOME A CLIENT CALL 406-541-3993 EXT 2

* Indicates required field

Client Name *

Debtors Name(s) *

Client Phone *

Client Fax *

Debtors last known home/cell phone(s): *

Debtors Social Security #(s) *

Client Address *

Line 1

Line 2

City

State

Zip Code

Country

Debtor(s) last know address: *

Line 1

Line 2

City

State

Zip Code

Country

Please read the following carefully and sign as indicated. Complete as much information as possible for each consumer. If there is anything unusual about the account, please let us know in the “Additional Information” section. For valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned does hereby sell, assign, transfer, and set over to Northwest Collectors the above listed debts, including, but not limited to, interest, service fees, damages, costs, or any other fees or amounts allowed by law or agreement with the debtor, authorizing and granting Northwest Collectors full right and power to collect, bring legal action, and discharge said indebtedness or claim in its own name and to do whatever it deems necessary to collect said amount. The undersigned covenants and represents that said amounts are justly due as of the received date and will provide verification upon request. Although payment may be received from the government, an insurance carrier, the debtor or any other source, this does not revoke or in any manner affect the assignment or Northwest Collectors’ right to the funds.

Client Representative Signature *

Date *

By giving your signature, you authorize Northwest Collectors to proceed with the collection on the debtor information provided on this form.

Interest collected will be retained by Northwest Collectors to help defray the cost of collection. It is understood that Northwest Collectors has the authority to start suit on this account if necessary. Northwest Collectors advances the costs of any such action. Monies due you from collections made will be paid after deducting these costs. Northwest Collectors does not guarantee collection of any assigned account.
PLEASE SEND A COPY OF THE ORIGINAL AGREEMENT SIGNED BY THE DEBTOR, SHOWING WHERE COLLECTION FEES AND/OR ATTORNEYS FEES CAN BE ADDED (IF ANY). Please send any additional supporting documents.

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

DOB 1: *

DOB 2: *

Cosigner /Guarantor Name(s): *

Additional Information: *

Balance Placed *

Date debt incurred or last charge date: *

Date of first delinquency *

Please fill out at least one of the the dates below before entering

Last payment date *

Judgment Date *

Charge-off Date *

Last statement date *

Transaction date *

Submit

​PLACEMENT OF NEW BUSINESS - FOR CLIENTS ONLYTO BECOME A CLIENT CALL 406-541-3993 EXT 2

Please fill out at least one of the the dates below before entering

PLACEMENT OF NEW BUSINESS - FOR CLIENTS ONLY
TO BECOME A CLIENT CALL 406-541-3993 EXT 2