Law Offices of Frank J. Maier and Associates

Transmittal of claim

** Helpful Hint: Fill in creditor information and make copies for future use.

Creditor Information

Name:
Address:
Phone:	Contact:
Debtor Information
Name:
Address:
Phone:	Social Security No:
Debt Information
Amount Owed:	$ Date Incurred (mm/dd/yy): Disputed (Y/N):
Nature of Debt:
Debtor's Work Place
Name:
Address:
Co-Debtor's Name:	Phone:
Address:
Work Place:
Additional Info:
* Please submit copies of contracts, invoices, statements, and applications along with any additional information you can provide us to help collect your debt. The Law Offices of Maier & Associates is hereby authorized to deposit all cash, checks, money orders and the like into their client's Trust account and to endorse said instruments as necessary to deposit. IT IS UNDERSTOOD THAT MAIER & ASSOCIATES WILL REMIT NET ON ALL MONIES COLLECTED.
Company Name:	Date:
By: