Account Placement

PLease fill out the account placement form completely.

Debtor Name:		Balance $:
Phone #	Fax #	Add'l Amt (Interest Fees, Etc)
Address:		Oldest Invoice Date:
City:	State: Zip:	Most Recent Invoice Date:
Individual Responsible:		Last Payment Date:
Your Customer Number:
Facts:

Desired Documents: Invoices, Statement of Account, Credit Application, Lien, Contracts, Personal Guarantee, Purchase Order, Proof of Delivery, Hot Checks, Bill of Lading. Any other information you feel my investigators may want to know, Please fax it along with this form to (281) 727-0831.

Document 1:		Document 2:

Document 3:		Document 4:

Your Company Name (Client):
Address:		Phone #:
City:	State: Zip:	Fax #:
Authorized By:		Date:

The client hereby authorizes Roma, Kirshbaum & Schmidt to represent them with the purpose of securing monies owed to them on their behalf. The client agrees to pay the agreed upon commission for any monies received by us or by the client from any source or returned merchandise from the date of the placement forward. We authorize Roma, Kirshbaum & Schmidt to accept payments, endorse checks, money orders, cashiers check and wire transfers for deposit. The net proceeds to be remitted to us on your set remit date upon clearing the bank. Special authorization is required to file suit or settle an account. By checking this box I agree to the above terms