Consumer Placement Form – TFC USA Associates

Debtor Information
Debtor
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home/Cell Phone*
Work Phone*
Email*
Social Security Number*
Driver's License
Amount Owed
Bank (Name & Address)
Account Number
Supporting Documents
Please attach all of the following documents you may have: itemized statements, invoice copies, proof of delivery, credit applications, credit reports, promissory note, return checks, copy of debtor checks, pertinent correspondence.
Creditor Information
Business Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Contact Person
First Last
Consent*
- I agree to the privacy policy & authorize TFC-USA to proceed
You hereby authorize Twenty-First Century Associates, to endorse in your company's name, and to negotiate or to deposit in any bank account of Twenty-First Century Associates, any and all checks, notes, drafts, bills, or exchange or other orders for the payment of money payable or endorsed to you which come into Twenty-First Century Associates, possession by virtue of its acting as your collection agent, and to remit the proceeds to you, less any fees which may be due whether or not such fees related to the claim for which the funds were received. Twenty-First Century Associates may use any funds collected to offset any open fees due Twenty-First Century Associates for any account submitted to Twenty-First Century Associates for collection. Where necessary your file may be sent to local counsel. If suit is required, counsel is entitled to a suit fee of no more than 10% of dollars collected.

Debtor Information

Creditor Information

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