NACM Connecticut Inc. PO Box 777 Glastonbury, CT 06033
Collection CLAIM PLACEMENT FORM
Only Commercial Claims Accepted
(Minimum CLAIM ACCEPTED $250)
10-DAY FREE DEMAND**  (Regular Service Follows automatically) IMMEDIATE PHONE CONTACT IMMEDIATE ATTORNEY PLACEMENT * AMOUNT DUE $
DEBTOR INFORMATION
Entities' Full Legal Name:*   Trade Style (d/b/a):   Business Type:* LLC     LLP     Sole Proprietorship Partnership     Corporation     sCorp     Other   Physical Street Address: * City:*     State:* Zip +4: *     Mailing Address: (if different from above) City:   State: Zip +4:   Contact Person: * Second contact person:   Telephone number:* Telephone number:     Cell Phone number:   Cell Phone number:     Fax number:   Debtor Account #:     Email address:   Email address:
SUPPORTING DOCUMENTATION
IF A REQUIRED ITEM IS UNAVAILABLE, PLEASE UNCHECK THE APPROPRIATE BOX AND SPECIFY WHY THAT ITEM IS UNAVAILABLE OTHERWISE THE CLAIM WILL NOT BE SUBMITTED. PLEASE EMAIL OR FAX THESE SUPPORTING DOCUMENTS TO: collections@nacmct.org / Fax (860) 659-1664
	* Credit Application (NACM CT needs the Credit Application to process this claim) * Any Signed Guarantees * Invoices * Any Contracts * Statement of Account * Provisions for Attorney Fees/       Collection Fees NSF Checks Correspondence Credit References

CREDITOR INFORMATION
Company:*
Contact:*
Telephone number:*
Member Number:*
Comments:
Is this claim disputed? Yes  No If yes, nature of dispute:
I hereby authorize NACM-CT, Inc. to report debtor's account status into NACM CT's national network? Yes  No
You will receive a confirmation email ONLY if you enter a valid email address here:
* REQUIRED FIELDS
By clicking on "SUBMIT CLAIM REQUEST BUTTON" you agree to the Terms and Conditions set forth by NACM Connecticut.