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SimpleTouchGroup-Law Office_____________ Office Use Only
Claim Placement Form
Creditor Information Creditor Company Name:________________________________________
Date:___________________Address:___________________Ste./Apt._______________________
City:_______________State_______________ Zip:______________Country:__________________
Mailing Address (If different): ________________________________________________________
______________________________________________________________________________
Phone:(__________):_____________________Fax:(__________ ):________________________
Contact Name::______________________Email:_______________________________________ Debtor Information
Debtor is:Corporation PartnershipSole Ownership
Debtor Company Name: ___________________________________________________________
Address: _______________________________________________________________________
City:_____________________________State:____________________Zip:___________________
Phone: (__________)____________________Fax: (__________)__________________________
Contact Name:______________________Title: _________________________________________
Email:___________________________________Original Amount:_________________________
Date of Original Invoice:_________________________________Social Security #:______________
Date of Last Payment:___________________________TOTAL DUE:_______________________
¾î¶»°Ô Çؼ 乫°¡ ¹ß»ýÇÏ°Ô µÇ¾ú½À´Ï±î (Loan, Sale of Goods, etc.):_________________________
_____________________________________________________________________________
乫ÀÚ°¡ 乫±Ý¾×À» ÁöºÒÇÏÁö ¾Ê´Â ÀÌÀ¯´Â _____________________________________________________________________________
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1. °í°´²²¼ 乫ÀÚ¿¡°Ô °ø±ÞÇÑ ¼ºñ½º´Â ¹«¾ùÀԴϱî
2. 乫ÀÚ¿¡ ÀÇÇØ Áö±ÞµÇ¾îÁø ¸ðµç Áö±ÞÇüÅÂ¿Í ³¯Â¥´Â ¾î¶»°Ô µË´Ï±î
3. °í°´²²¼ 乫ÀÚ¿Í ¿¬°áµÇ¾î °æÇèÇϽŠ´Ù¸¥ ¹®Á¦´Â ¾ø½À´Ï±î
4. ä±Ç Ãß½ÉÀÇ Áß¿äÇÑ ºÎºÐÀ¸·Î °³ÀÎÀûÀ¸·Î ¼¸íÇϰųª ¹ÞÀº ³»¿ëÀÌ ÀÖÀ¸½Ê´Ï±î
5. ¸ðµç Áö±ÞÇüÅ¿¡ ´ëÇØ Ã¤¹«ÀÚ¿¡°Ô ¾Ë¸° ³¯Â¥¿Í ¾î¶»°ÔµÇ¸ç, ³»¿ëÁõ¸íÀ» °¡Áö°í °è½Ê´Ï±î
6. ¾ðÁ¦±îÁö 乫ÀÚ°¡ Áö±ÞÇÏ°Ú´Ù°í ¾à¼ÓÇÑ ³¯Â¥³ª Áõ¸íµÈ ³»¿ëÀ» °¡Áö°í °è½Ê´Ï±î ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
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Simple Touch Group
4214 BEVERLY BLVD. STE 207
LOS ANGELES, CA 90004
TEL: 213-252-9550
FAX: 213-251-9890 |
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