|
_______________________
DATE
_______________________
CLIENT NAME
_______________________
CONTACT
_______________________
RATE
_____________________________________________
DEBTORS NAME
_____________________________________________
ADDRESS
_____________________________________________
CITY
_____________________________________________
STATE, ZIP CODE
_____________________________________________
PHONE
_____________________________________________
FAX
_____________________________________________
CONTACT
_____________________________________________
DATE OF LAST SALE OR DATE OF NONSUFFICENT FUND CHECK (AND CHECK NUMBER)
_____________________________________________
AMOUNT OWED IN FULL
_____________________________________________
TYPE OF BUSINESS
_____________________________________________
COMMENTS
ATTACH COPIES OF
INVOICING TO SUPPORT CLAIM
|
