Debt Collection in Lakewood and Denver Colorado - Client Services

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Client Services - Refer an Account

Fill out the form below, being as complete as possible, and provide any additional information that may be useful in assisting us in collecting your account.

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Please note: fields marked with an asterisk (*) are required to process your submission. If you do not have information for one of these fields, type "N/A".

Your Information:

Debtor Information:

* Name:
SSN:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone:
Last Known Employer:
Employer Phone:

Co-Debtor Information:

Name:
SSN:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone:
Last Known Employer:
Employer Phone:

Account Information:

By submitting an account for collection, you agree to the contingency fee agreement and disclosure statement we have for you on file. If you have not yet signed a Collection Agreement, a RMB Services representative will contact you.

Referring account. One moment, please.

This is an attempt to collect a debt by a debt collector. Any information obtained will be used for that purpose.

* Your Name:
Your Title:
* Company Name:
* Address 1:
Address 2:
* City:
* State:
* Zip Code:
* Phone Number:
Fax Number:
* Valid E-mail Address:
* Business Type:

Account Ref. #:
* Principal Due:
Interest Due (if any):
Interest Calculated Through Date:
Interest Rate:
Misc. Amount Due (if any):
* Date of Last Payment:
* Charge-Off Date:
Type of Account: (Check all that apply)	Credit Card Medical Education - Tuition Education - Perkins Education - DULF Retail Personal NSF Check Auto Loan Commercial Judgment Other
Comments:
Do you have a digital copy of the Proof of Debt? Proof of Debt File:	Yes No .pdf, .doc or .xls file format only. .pdf, .doc or .xls file format only. .pdf, .doc or .xls file format only.