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Creditor Information

Company Name

Contact Name *

Company Address *

City *

State / Providence *

ZIP / Postal Code *

Country

Phone *

Fax

E-mail *

Debtor Information

Debtor Name *

Debtor Address *

City *

State / Province *

Zip / Postal Code *

Phone

SSN

DOB

Case#

Date of debt incurred for collection or judgment ordered? *

Damage Amt$ *

Briefly Explain Claim: *

Have you collected any amounts on this claim? *

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How much collected? *

Do you have any banking account information on debtor? *

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Do you have pictures and supporting documents? *

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Upload supporting documentation *

By submitting this form you agree to our "Terms and Conditions and certify the information provided is accurate." Upon submitting this form we will evaluate collectability and respond back to you as soon as possible. Submission does not constitute agency relationship nor an engagement of services.

FDCPA Compliancy

Green, Richard and Trent is a licensed and professional collection agency. We are respectful of others and compose our business in a manner of respect and dignity to all. As such, we are cognizant to the rights of debtors and remain fully FDCPA compliant at all times.

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