Please fill out this claim form and one of our representatives will contact you shortly. If you wish to mail or fax this form, you may download a copy in PDF format. If you do not have Adobe Acrobat Reader click here for your free copy. * Required Fields are in BOLD.


Date: March 23, 2018, 2:48 pm
CREDITOR INFORMATION (address information required for new clients only)
Company Name:  
Email Address:  
Address (required for new clients only):  
City, State, Zip (required for new clients only):    
Report To:  
Division Location:  
DEBTOR INFORMATION (Required Fields are in BOLD.)
Account Name:  
Principal or Person to Contact:  
City, State, Zip:    
Phone Number:
(include area code)
File or Reference Number:  
Amount Due:   $ Date of last transaction :
Additional Interest:   $
Total Amount:   $
You can attach any documents supporting your claim below. Please organize your documents in one file (can be a PDF, .ZIP Archive, Word Document, etc.). If you would prefer to attach your documents as a .ZIP archive, a FREE copy of WinZip can be downloaded here. Alternatively, Enclosures /Attachments can also be mailed to the address at the bottom of the page.
Document Types:  

Statement   Invoices  Credit Report  N.G. Checks or Notes


Special Instructions or Comments:  
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78206 Varner Rd. #132 Palm Desert, CA 92211
Tel (818) 407-4040 Fax: (818) 407-2727
Internet Consulting Services by Walker & Company