Commercial Collections - Certified by the CLLA and CCAA


	Date:

*	CREDITOR:
	Address:
	City, State, Zip:
	Credit Executive:
*	Phone:
	Fax:
*	E-mail:

*	DEBTOR:
	Customer Reference #:
*	Address:
*	City, State, Zip:
	Contact:
*	Phone:
	Fax:
*	Date Last Inv.:
	Date Last Pymt.:
	Report to Credit Bureau:	Yes No

*	AMOUNT:	$

*	Select Starting Service:	Immediate Action Immediate Litigation Free Demand Letter Requesting that payment be made within days (not to exceed 10 days)
	Will be mailed or faxed:	Itemized Statement Credit Report Original Contract Pertinent Correspondence NSF Checks Notes or drafts Personal Guaranty

	Date and results of last conversation with Debtor

	* Required Fields

Mountain States Commercial Credit Management Phone: 800-457-8244 303-806-5300 Fax: 303-806-5360 e-mail: info@msccm.com 333 W. Hampden, Suite #425, Englewood, Colorado 80110 ©2001 Mountain States Commercial Credit Management, Inc. All rights reserved. Developed by Data Technology Services, Inc.