Name of Debtor:

Address:

City:

State:

Zip:

Tel #:

Date First Unpaid Invoice:

Date Last Unpaid Invoice:

Date of Last Payment:

Total Amount Owed:

Brief synopsis of debtor's history.......

Your Company Name:

Address:

*Your Company Email:

City:

State:

Zip:

Tel #:

Fax:

Authorized by:

Today's Date:

Remit Address:

We authorize Kramer, Fox & Associates, Inc to represent our company in the collections of the above account. We authorize you as our agent to accept payments, endorse checks, money orders, or bank drafts for deposit. All monies received by the agency will be reported to the client immediately. All clients of Kramer, Fox & Associates, Inc will receive remit ten days after the debtor's check clears the bank. If you the client receive, any monies from the debtor Kramer, Fox & Associates, Inc will then invoice the client for our fee.