6355 Topanga Canyon Boulevard
Suite 255
Woodland Hills, CA 91367
T 818.360.6697
F 818.593.2180
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IMMEDIATE PLACEMENT FORM
Please accept this notice as an assignment for IMMEDIATE COLLECTION of the below account,
pursuant to your rate schedule.
Please note: attachments to this on-line placement claim form must be E-mailed
under separate cover to
clientservices@ncsiweb.com
Date
Creditor *
(Name of original creditor or company placing file):
Street Address / Po Box
City, State, Zip
Phone and Extension*
Assigner / Creditor / Executive / Manager:
Email Address*
Debtor
(company name or individual name)
Street Address / Po Box
City, State, Zip
Phone and Extension
Balance Due
Email Address
Remarks
bridging the gap between
creditors and debtors
