Acceptance of Collection of Claim

Date: _______________________

To: ________________________

Receipt is acknowledged of your claim against ________________________________ for ___________ ($________).

Your claim is accepted for collection under the following terms and conditions:

____________________________________________

____________________________________________

Our experience of contacts with the debtor are shown by check marks preceding theappropriate statements:

[ ] 1. Personal demand is being made upon the debtor. A further report will be made to you in _________ days.

[ ] 2. The debtor is slow in payment, but we believe that we can collect your claim without suit.

[ ] 3. The debtor must be sued. If you desire suit to be filed, please send duplicate invoices, statements of account, and the enclosed affidavit, properly executed, together with your check for ____________ ($_______) to pay estimated court costs and attorney fees.

[ ] 4. The debtor generally remits payment to the creditor immediately on our demand.

Kindly advise us of direct remittances.

[ ] 5. The debtor is in bankruptcy. Please execute the enclosed proof of claim and power of attorney and return them to us at once.

[ ] 6. We have had ____________ claims against the debtor and have now collected on ___________ of them.

[ ] 7. We now have claims against the debtor and are collecting them: ____________________________.

[ ] 8. This debtor disputes the claim. Please furnish additional information concerning the claim and send us all original correspondence, together with any original orders, written acknowledgments, or promises to pay.

[ ] 9. This debtor is: (a) out of business, (b) has no property that can be levied on, and (c) is not earning sufficient wages for garnishment. However, we believe payment will be made as soon as possible. We will try to persuade (him/her/them) to pay and keep you advised unless you advise us to return the claim to you.

_________________________
Signature

_________________________
Title

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