Ross, Stuart & Dawson - Commercial Claim Placement Form
* Asterisk Indicates Required Fields
Debtor Company Name *
Debtor Street Address *
Debtor Suite, Apt #, Floor, Etc.
Debtor City *
Debtor State *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Debtor Zip / Postal Code *
Debtor Phone *
Debtor Cell Phone
Debtor Fax Number
Debtor Email Address
Debtors Account Number *
Debtor Total Amount Due $ *
Debtor Invoice Date (Oldest) *
Debtor FED Tax # / Social Security #
Debtor Contact Name *
Debtor Contact Title *
Debtor Bank Name
Debtor Bank Account Number
Debtor History - Check All That Apply *
Claims Inability To Pay
Mail Returned
Disputed
Check Returned
No Response
Phone Disconnected
Additional Information / Comments
Document Checklist *
Please send all documents to RSD via email, fax or U.S. Mail.
Personal Guarantees, Notes, etc.
Proof of Delivery/Receipts, etc.
Statement copies
Invoice(s) copies
Signed Contract/P.O./Credit Application, etc.
Credit report
Creditor Info - RSD Client Name *
Claim Submitted By *
Street Address *
Suite, Apt#, Floor, Etc.
City *
State *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip / Postal Code *
Phone Number *
Email Address *
Existing Clients - Please Read
EXISTING CLIENTS: By submitting your claim for collection, you are agreeing to the terms and conditions as set forth in our client agreement for the type of claim placed.
New Clients - Please Read
NEW CLIENTS: If you are a new client and have not entered into an agreement with our agency, an RSD representative will contact you shortly to review our rates, terms and conditions. Should you have any questions regarding this process, please call us at 1-888-701-8181 and we will be happy to assist you.
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