New Account Claim Form

International Collection Service, Inc.
255 South Tamiami Trail
Nokomis, Florida 34275
1-800-868-2540
1-800-868-2518
MHawley@icsdebt.com

New Account Claim Form:

Client Section:

If you are an established client with ICS, all we need in this section is your name, company, and phone.

If this is your first time placing an account with ICS for collection, please fill out this entire form.

Your Name:*
Your Company:*
Your E-Mail:
Your Address:
Your City:
Your State:
Your Zip:
Your Phone:*
Your Fax:

Debtor Section:

In this section of the form, please include as much information as possible about the person(s) you are placing for collection.

Information is key in recovering your money, so please be as detailed as possible.

Debtor Name:*
Debtor Address:
Debtor City:
Debtor State:
Debtor Zip:
Debtor Phone: Home
Debtor Phone: Work
Debtor Phone: Mobil
Debtor Phone: Other
Debtor E-Mail:
Date of Birth:
Social Security Number:
Employer:
Spouse:
Date Last Charge:
Date Last Pay:
Your Account # For This Debtor:
Principal Amount Due:*	$
Interest Amount Due:	$
Other Amount Due:	$
Total Amount Due:	$
Do you have an agreement to charge interest?	Yes No
Comments :

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Suncoast Lung

"[ICS has] eased the burden of our accounts receivable department."

Guaranteed Results

ICS will collect 40% more than your current agency in 90 days or pay you the difference in CASH. Guaranteed!