MCH Placement Form

Place A Claim

Free Demand Service Immediate Collection

Creditor Information

Creditor Company

Address

City State/Provinces

Zip Country

Phone Fax

Name Title

E-Mail

Debtor Information

Debtor

Address

City State/Province

Zip Country

Amount Date Last Charge Last Payment

Phone Fax

Contact E-Mail

Is Mail Returned ? Yes No Is account disputed ? Yes No

Comments:

MCH is herewith authorized to endorse & deposit, or negotiate, checks, drafts, etc, on this account in the name of the Creditor. MCH is entitled to its commissions on all reductions in the amount claimed on this account, whether paid to MCH, Creditor, or another party. Immediate Collection automatically follows Free Demand on any unpaid balance. This claim/These claims is/are submitted under current rates, terms & conditions.

Mandatory Validation of Form:

Please type in the code to your right so we know this is a legitimate request. Letters are case sensitive.

pTNLb694