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Account Submissions Form

 

  *required fields
*Clients Name:
Address:
City:
State:
ZIP:
Phone No.:
 (ex: 555-555-5555)
Authorized by:
Title:
 
In submitting this list, the credit grantor gives assurance to the agent, that it (or he/she), has complied with the disclosure and other provisions contained in Truth in Lending.
 
Debtor's No.:
*Debtor's Full Name:
Spouse:
*Address:
*ZIP:
Phone:
 (ex: 555-555-5555)
Debtor's Social Security #:
 (ex: 123-45-6789)
Spouse Social Security #:
 (ex: 123-45-6789)
Account Disputed: Mail Ret'd:
Employer:
Work Phone #:
 (ex: 555-555-5555)
Spouse Employer:
*Date of Last Charge:
 (MM/DD/YYYY)
Date of Last Pay:
 (MM/DD/YYYY)
Amount: $
Interest: $
*Total Due: $
Additional Information (relatives, references, etc.)
 

 
main office 206.624.1661
Eastern Washington 509.433.1062
fax 206.624.0258
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