The Law Offices of Jeffrey J. Needle, P.A.

To submit a claim, please fill in the form below

and a client liaison will be in touch within 24 hours to discuss your matter or claim in specific detail. Should you choose to engage this firm to represent you or your company in any matter, we will forward to your attention a claim authorization/retainer agreement allowing this firm to represent your interests in this matter and explaining all terms and conditions of the representation. Before we can proceed with any claim on your behalf, we must receive the claim authorization form mentioned above and you may be required to forward to us, any additional paperwork or information necessary to effectuate your claim.

Effective & Expedient Debt Collection

The Rules Regulating The Florida Bar [4-1.5(f)(2)] require that contingent fee agreement must be signed.

Please Fill In Debtor Information Here

Debtor Name Contact

Address 1 Address 2

City State Zip Code

Select The Country You Are In

Phone Cell Phone Fax

Email Address Web Address

Information On Receivables To Place For Collection

Total Debt To Place Number of Accounts

Description of Debt

Avg Placed Monthly Avg Age of Debt

General Location of Debtors - City State

Debtors Country

Please Check All That Apply For The Receivables You Wish To Place

Written Contract Oral Contract Judgment Promissory Note Loan

Short Term Note Long Term Note In-House Credit Plan

Ever placed with a collection provider previously?

Special Requirements Of Collection Provider or Additional Comments

Creditor / Your Information Goes Here

Full Name

Title

Company Name

Address 1 Address 2

City State Zip

Phone	Fax	E-mail

Please institute no proceedings, incur no expenses, make no compromises and/or grant extensions without written authorization. All payments less your commissions must be remitted as received. Collect interest wherever possible. Claimant prefers all correspondence be conducted through our office.

This account is forwarded in accordance with the operative guides and receivers adopted by the commercial law league of America, to which we subscribe. Failure to acknowledge claim, answer letters, or follow claimants instructions, will leave claimant free to recall this claim without payment of commissions to you. Report promptly the possibility of collections. If suit is advisable, state exactly what papers and cost you will require. Charges and disbursements due on other claims must not be deducted from the amounts collected on this claim.

If these terms are not acceptable, please return immediately stating the reasons. Please acknowledge receipt, stating whether the terms and conditions are satisfactory.

Mandatory Validation of Claim Form

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

KNJUe574

DISCLAIMER: The hiring of a lawyer is an important decision that should not be based solely upon advertisement. Before, you decide, please ask us to send you free written information about our qualifications and experience.

Should you choose to engage this firm to represent you or your company in any matter, we will forward to your attention a claim authorization/retainer agreement allowing this firm to represent your interests in any matter and explaining all terms and conditions of the representation. Before we can proceed with any claim on your behalf, we must receive the claim authorization form mentioned above and you may be required to forward to us, any additional paperwork or information necessary to effectuate your claim. The Rules Regulating The Fort Lauderdale Bar [4-1.5(f)(2)] require that contingent fee agreement must be signed.

A Florida Collection Law Firm - Toll Free 1-800-367-1174

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