Home
About
Law Offices of Goldsmith & Hull A.P.C.
Firm Leadership
Services
Collection
Subrogation
Personal Injury
Medical Malpractice & Professional Liability
Insurance Matters
Insurance Bonding Issues
Insurance Coverage Issues
News & Updates
Contact
(818) 990-6600
Submit Collection Claim
Make Payment
Home
About
Law Offices of Goldsmith & Hull A.P.C.
Firm Leadership
Services
Collection
Subrogation
Personal Injury
Medical Malpractice & Professional Liability
Insurance Matters
Insurance Bonding Issues
Insurance Coverage Issues
News & Updates
Contact
(818) 990-6600
Submit Collection Claim
Make Payment
Submit a New Collection Claim
New Claim or Judgement?
New Claim
Judgement
Client's Full Name
*
First Name
Last Name
Name of Business
Type of Entity
Corporation
LLC
Partnership
Sole Proprietor
D/B/A
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
(###)
###
####
Fax
(###)
###
####
Tax ID #
*
Debtor Information
Debtor's Full Name
*
First Name
Last Name
Type of Entity
*
Corporation
LLC
Partnership
Sole Proprietor
D/B/A
Debtor's Social Security #
*
Debtor's Driver's License & State
*
Debtor's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Debtor's Email
*
Debtor's Phone
*
(###)
###
####
Debtor's Bank Name
Debtor's Bank Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Debtor's Bank Account #
Debtor's Spouse's Name
First Name
Last Name
Debtor's Children's Names & Ages
Known 3rd Party Contacts
Relationship to Debtor
Coborrower's Name
First Name
Last Name
Coborrower's Driver's License & State
Coborrower's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Coborrower's Email
Coborrower's Phone
(###)
###
####
Coborrower's Social Security #
Debtor's Employer's Name
First Name
Last Name
Debtor's Employer's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Debtor's Employer's Email
Debtor's Employer's Phone
(###)
###
####
Debtor's Employer's Fax
(###)
###
####
Debtor's Immediate Supervisor's Name
First Name
Last Name
Department
How Long Has S/He Worked There?
Coborrower's Employer
Coborrower's Employer's Driver's Licence & State
Coborrower's Employer's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Coborrower's Employer's Email
Coborrower's Employer's Phone
(###)
###
####
Original Creditor
If different
Can You Provide Copies of Original Contracts?
*
Yes
No
Can You Provide Copies of Original Purchase Orders?
*
Yes
No
N/A
Can You Provide Statements?
*
Yes
No
N/A
Can You Provide Credit Reports Run Recently?
*
Yes
No
N/A
Reason Debtor is Not Paying
*
Amount of Claim
*
$
Principal Due
$
Interest Due
$
Interest Rate
Attorneys Fees Due
$
Miscellaneous Due
$
Balance Due
$
Date of Last Payment or Date Debtor Breached Agreement
MM
DD
YYYY
Last Payment Amount
$
Any Other Comments or Information to Help Collect This Debt?
Thank you!
