DATE:

STREET ADDRESS:     PHONE:

FAX:

CITY:      STATE: ZIP:

Placement Amount: $    

SERVICE REQUESTED:

Immediate Collection

Free Demand

In order to expedite our efforts, any of the following information that is available from your credit and collection files would be appreciated:

1.  Name of responsible individual (s)

2. Debtor's business phone

3.  Debtor's banking connection

4.  Debtor's business type  Corporation     Partnership     Sole Owner

5. Your experience with debtor   Broken Promises  NSF Checks  Dispute  Out of Business    Ignores all Demands

6.  Enclosures  Guarantees  Statement  Invoices  Correspondence  NSF Checks  Credit Report  Other

7. Special Instructions:

By pressing the "Submit" button at the bottom of this page you agree to the following:

You are hereby authorized to endorse in the name of the undersigned and to negotiate or to deposit in any bank account of yours, any and all checks, drafts, bills of exchange or other orders for the payment of money payable or endorsed to the undersigned which come into your possession by reason of your acting as Collecting Agent for the undersigned and their firm.

FROM: CREDITOR        PHONE:

FAX:

STREET ADDRESS:              CREDITOR CONTACT:

CITY:    STATE:   ZIP:

This account is hereby referred for collection to Diversified Credit Service (DCS) and authorization is given to proceed immediately to collect the amount referenced. Commissions will be charged on accounts collected, whether or not they are collected through this office or paid direct. Accounts settled through return of merchandise will generate a collection fee equal to 50% of the quoted rate. In the event litigation is deemed necessary DCS will have the authority to involve the services of an attorney in the area where the debtor is located. Legal rates will apply as quoted. DCS operating as agent, is authorized to accept payments and endorsed checks, notes, money orders or drafts for deposit. Proceeds will be remitted upon clearance of such items. Special authorization is required to file suit, compromise or grant an extension beyond a reasonable time frame. Cancellation of account during collection will not negate the collection fee which will apply to claims withdrawn while collection pending. Any payments made direct to this office will be reported immediately and fees apply from the date of placement unless otherwise specified. A free-demand period of ten days will apply to claims if indicated. The free-demand applies to payments reported within the ten-day period from the placement date.