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ASSIGNMENT FORM
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CLIENT INFORMATION

CLIENT NAME AND CONTACT PERSON

STREET ADDRESS

CITY, STATE AND ZIP CODE

TODAY'S DATE

YOUR PHONE NUMBER

YOUR FAX NUMBER

YOUR REFERENCE NUMBER

 DEBTOR INFORMATION

DEBTOR’S NAME

CONTACT PERSON/TITLE

STREET ADDRESS

CITY, STATE AND ZIP CODE

AMOUNT DUE                               $

DATE OF LAST TRANSACTION

PHONE NUMBER

FAX NUMBER

 

PLEASE INCLUDE A CURRENT ITEMIZED STATEMENT OF ACCOUNT, INVOICES, CREDIT REPORT, AND ANY OTHER ADDITIONAL INFORMATION ON THE DEBTOR. USE ADDITIONAL PAGES AS NECESSARY

CLIENT hereby submits this and all future accounts to George L. Cohn dba
Collection Lawyers pursuant to the terms of our Retainer Agreement.

CLIENT NAME

TITLE

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DATE

 

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