Claim Form
ON LINE CLAIM FORM

Submit your debt claim on line.  We will evaluate the claim and promptly advise you whether we will accept your debt claim.  No legal action will be taken without your prior approval.
* required

DEBTOR

        Name*

     Organization*

  Street Address*

   Address Cont*

                    City*

                  State*

           Zip Code*

     Work Phone*

    Home Phone

                    Fax*

                Email*

CREDITOR

                 Name*

     Organization*

  Street Address*

  Address Cont.*

                    City*

                  State*

           Zip Code*

     Work Phone*

    Home Phone

                    Fax*

                Email*



FORWARDER

         Company

           Address

                   City

                 State

          Zip Code

              Phone

        Extension

               Email

           Contact


CLAIM AMOUNT*


Brief Description of Claim* (include
whether contract, goods sold and
delivered, services, transport,ins.
premium or other) 



Please send all available back up documentation by PDF to:  dfass@klapperfass.com

Copyright 2011 Klapper & Fass:  New York Debt Collection.  All Rights Reserved.
170 Hamilton Avenue, White Plains, NY  10601
(914) 287-6466 | dfass@klapperfass.co