CONSUMER LISTING FORM
Debtor Name:
Last First Middle
Address
2nd Address
City Zip -
Phone Number --  
Driver License Date of Birth
Previous Address
Previous City Zip -
Previous Employer
Present Employer
Business Phone -- Fax Number --
E-Mail Address
Spouse Name:
Last First Middle
Spouse Employer
Debtor Bank
Amount of Claim $ Date of Last Charge  
Last Payment $ Date of Last Payment
Claim:
Book Account Agreement/Note/Contact NSF Check Judgment
Additional Information:
We hereby assign to THE NATIONAL COLLECTION AGENCY, INC., our claim listed above, together
with the demand represented thereby with full power to collect, sue for, re-assign, or in any other manner
enforce collection thereof, in its own name or otherwise. All sums collected in addition to the balance
due as above listed shall be retained by you, excepting court costs advanced by us. The above claim is
assigned at fifty per cent contingent, unless otherwise specified by assignee.
Creditor
Address
City Zip -
Phone Number -- Email Address





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