Darlington Claim Form

LAW OFFICES OF: Ziegler, Metzger & Miller Attn: Steve Darlington, Esq. 925 Euclid Ave., Suite 2020 Cleveland, OH 44115		Phone: 216 781-5470
		Fax: 216 781-0714

Print for faxing or mailing

Debtor Information:
Debtor Name:
Person to Contact:
Address:
Additional address line:
City:	State:	Zip:
Principal Amount Due:

Account Number that you use to identify your customer:

Date of Oldest Invoice:	dd/mm/yy		Date of Last/Final Invoice:
Debtor's Area Code:		Debtor's	Phone:	-

Service Agreement: It is agreed that the fee for this claim will be 25% with or without suit. On a case by case basis, a non-contingent suit fee or other contingency rates may be warranted. The decision to file suit remains the decision of the Creditor. It is understood that commissions will be charged on all accounts collected, paid direct, withdrawn, or settled by the return of merchandise.

If you are placing a foreign claim, please place your claim by fax or mail and hand write the foreign phone number, zip code and required address format (if known)


Creditor Information:
Your Company Name:
Your Name:

Address:
City:		State:		Zip:

Your Area Code:		Your Phone Number:	-
COMMENT: