CCR Collections America, Terms, Commercial and Consumer Recovery America, Collections, Skip Tracing, Credit Services, Collection Solutions, American Collection Agency

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Client Information
	Client name:	Telephone:
	Contact Name:	Fax:
	Location No.:

Purchaser Information
	Account No.:	Address:
	Relationship:	City:
	Surname:	State:
	First Name :	Zip Code:
	Home Phone:	Work Phone:
	Cell Phone:


Beneficiary Information
	Name of Decedent:	Date of Death:
	Birth Date:	Address:
	Social Security No.:	City:
	Sex:	State:
	Marital Status:	Zip Code:
	Occupation / Employment:

Accounting Information
	Contract Amount :	Balance Due:
	Less Payments:	Interest Rate %P/A:

Additional Information
	Description:

Disclaimer Commission applies on accounts paid to Agency or the Client and is based on the applicable CCR Fee schedule. It is mutually agreed between the parties, that if Client withdraws any account, the account will be subject to a fee equal to the successful collection of that account except where, in CCR's opinion, the debt is deemed not collectibale. CCR may enter into compromise settlements of not less than 75% of the principal balance due without prior consent or approval, unless otherwise agreed. The cost of credit card and ACH transactions are shared, and adjusted as settled amounts. By submitting this account, Creditor certifies that all charges are in accordance with all applicable laws and authorized in writing by the agreement between Creditor and the Responsilbe Party. Creditor agrees to hold CCR harmless from any such violations. I accept these terms and conditions.

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