CLAIM FORM

To initiate a claim for CCSI to process
please fill out and submit this form

	Client / Creditor Information:
Date:
eMail Address:
Company Name:
Address:
City, State & Zip Code:
Telephone:
Fax:
Submitted By:
	Debtor Information:
Claim Amount:
Oldest Invoice Date:
Debtor's DBA's:
Address:
City, State & Zip Code:
Contact Names:
Business Telephone #'s:
Business Fax #'s:
Residence Telephone #'s:
	Proceed with immediate collection
	10 day free demand service
Additional Information:

After online transmittal send us supporting documentation via regular mail or fax (508-252-3460)

Coastal Credit Services. Inc. acting as a collection agent is authorised to deposit sums collected to its trust account, and when deemed necessary select an attorney to represent you.