Levy Claim Form

LAW OFFICES OF: Levy, Davis & Maher, LLP Attn: Damon R. Maher, Esq. 29 Broadway, 9th Floor New York, NY 10022		Phone: 212 371-0033
		Fax: 212 371-0463

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 It is understood that commissions will be charged on all accounts collected, paid direct, withdrawn, or settled by the return of merchandise.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: