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General Information: Business/Organization Name * :
Contact Person * :
Telephone * :
Street Address * :
City * :
State * :
ZIP * :
Fax * :
Email * :
Comments :
Debtor Information: Person Responsible for Debt * :
Debtor Home Telephone :
Debtor Street Address * :
Debtor City * :
Debtor State :
Debtor ZIP :
Social Security Number :
Date of Birth :
Occupation :
Employer :
Employer Telephone :
Name of Spouse :
Spouse Address :
Spouse City :
Spouse State :
Spouse ZIP :
Spouse Date of Birth :
Spouse Employer :
Spouse Employer Telephone :
Spouse Social Security Number :
Debt Information: Invoice/Reference Number :
Date Debt Incurred * :
Last Payment Made :
Do you have a signed contract :
Do you have any written disputes regarding debt :
If Yes, Please Explain :
Description of Debt * :
Original Amount of Debt * :
Accrued Interest :
Additional Fees/Charge :
Total Amount Due :
Any other information you feel may assist us in locating/collecting this debt :
   
 
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RMI is a licensed and bonded collection agency in the states of Illinois, Indiana, and Florida.
Member of Illinois Collectors Association, American Collectors Association, and Better Business Bureau