Creditek Recovery Solutions
Claim Form

FROM

Name:

Title:

Company Name:

Mail and Street Address:

City: State/Province:

Zip/Postal Code: Country:

Phone Number: Fax Number:

E-mail Address:

DEBTOR INFORMATION

Name:

Company Name:

Mail and Street Address:

City: State/Province:

Zip/Postal Code: Country:

Phone Number: Fax Number:

E-mail Address:

Invoice Date:

Debtor's Last Payment Date: Amount:

Total Amount Due:

Any comments, questions or special instructions:

To Send in This Claim,

Print out the entire form so you'll have a copy of what you've just typed, then press the Submit button below.

If you wish, you can fax us your print-out to 1-856-439-0559 with any necessary invoice or statement copies.