MANAGEMENT KONCEPTS, INC.

COLLECTION AGENCY AND MEDICAL BILLING SERVICES
   

Debtor Online Form

DEBTOR COMPLAINTS / COMMENTS / CREDIT BUREAU INQUIRIES

Date: YY/MM/DD 
    Your Account Info:
Client You Owe: Your Acct #:

Your Info:

Your Last Name:    
First Name: M.I.:
Your email address: Your Social Security #:

YOUR ADDRESS:

Address: City:
State: Zip:
Your home phone: Work Phone:

PAYMENT INFO:

Payment date: Amount Paid:
Check / M.O. #:
   

COMMENTS/ Complaint/ Credit Bureau Inquiry Info:

Please give as much detail as possible.

If a credit bureau inquiry or dispute please input the 17 digit number shown on the credit bureau report to insure we get the right account.

Credit bureau I.D. # : 



Comments:


 


Additional comments:

 

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