Request for Collections form

We will be in contact with you WITHIN 48 HOURS with an update or PAYMENT IN FULL.
Form to be used by ACS Clients only

Debtor Details

Date of request

Customer Account Number

Your account Number

Primary Debtor / Company

Name

Provide full legal entity

A.C.N. number

A.B.N. number

Do you have a Director's Guarantee?

Yes

Address

Country

City

State

Zip code

Postal Address (if different)

Country

City

State

Zip code

DOB

Mobile

Telephone (b/h)

Telephone (a/h)

Email address

Secondary Debtor

Name of debtor

Provide full legal entity

Address

Country

City

State

Zip code

Postal Address (if different)

Country

City

State

Zip code

DOB

Mobile

Email address

Telephone (b/h)

Telephone (a/h)

Debt Details

Services / Items ordered

Original amount of debt

Amount paid so far

Amount to collect

First & last date of invoice

Cause of Action

Please specify

Action Required

Legal action

Telephone demand

Ring client to discuss

Notes for Collector

Client Details

Name of Your firm

Provide full legal entity

Industry

A.C.N number

A.B.N number

Contact name

Telephone

Address

Country

City

State

Zip code

Email address

Attachment 1