Debt Collection Assessment Inquiry Form

*Name of contact person:

Business:

*Address:

*Phone

Fax

*E-mail address:

*Name:

*Current address:

*Country:

Phone:

Fax:

E-mail address:

(other please specify below)

Other debtor's status:

*Name and position of legal representative:

Outstanding amount:*

Nature of debt:*

(e.g. goods sold and delivered, services rendered, dishonoured cheque)

Invoice date:*

Invoice number:*

Due date:*

Payment terms:*

(days)

Contractual interest rate:

(if applicable)

Remarks:

Additional documents:

(allowed formats: jpg, png, gif, txt, doc, xls, ppt, pdf, zip; for other formats or more than one file please use zip)

* required

All inquiries are treated confidentially. Completion of a form does not create a professional relationship with Eiger Law.