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SUBMIT A CLAIM

The following form is for your convenience. Creditor consents to Greene & Cooper's use of any information provided by Creditor in pursuing collection of the account. Creditor represents and warrants to Greene and Cooper the truth and accuracy of the information provided.
 
Debtor Information
 
Debtor Name :
Address:
City:
State:
Zip:
Amount Due:
Contact Name:
Phone:
Fax:
Email:
Acct #:
NSF Checks
Dispute Furnish Details
Remarks:

 

Client Information
Company:
Contact Person:
Email:
Address:
City:
State:
Zip:
Phone:
Fax:
 
To expedite collection - we may request copies of all available documents such as itemized statements - credit reports - purchase orders - signed applications - original NSF checks