Please print this page, fill out, sign and fax to (954) 963-9219


Joseph F. Whitehead, P.A.
attorney at law

Client acknowledges that any payment made by the accounts after the P.A.’s first contact is due solely to the efforts of the P.A.  The contingency fee vests after the P.A. has made any contact with the accounts.  The contingency fee is earned as to any value Client applies to the balance of the accounts given to the P.A. for debt reduction.

Should Client terminate accounts prior to the P.A.’s opportunity to exhaust all lawful efforts where a reasonable possibility of actual debt reduction exists or otherwise work the accounts to a reasonable conclusion, the P.A., is entitled to penalties of twenty percent (20%) of the accounts value or forty percent (40%) if the account has been forwarded to litigation counsel.  Should P.A. obtain no value or otherwise reduce the amount owed by the accounts after all efforts or a reasonable conclusion, Client owes no fee or costs.

Client authorizes the P.A. to deposit checks payable to Client as Client’s agent in order to expedite the proper handling of the accounts and to insure clearance of all debtor checks.

 

Firm ______________________________________      Date___________________



Address___________________________________     City____________________



Authorized by_______________________________     Tel. ___________________

Signature:___________________________________   Fax: __________________
 

Please accept the following account for collection.

Debtor Name:
 
Address:
         

City,State,Zip:


Business Type:


Individual Responsible :




 

Facts:




Amount Due:          




Telephone:




Fax:




Date of Bill:            




Date last payment:




Invoice #:


 


Please fill out, sign and fax to (954) 963-9219
5201 Ravenswood Road • Suite 111 • Ft Lauderdale, Florida 33312
Tel. (954) 963-9219            Fax: (954) 963-9219

1. If you wish to download a printable copy of our collection form to fill out and fax back in Adobe™ Acrobat PDF format. Click here.

2.
1. If you wish to download a printable copy of our collection form to fill out and fax back in Microsoft Word format. Click here.

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