Collection Attorneys in Lakewood Colorado Collection Lawyers - Refer an Account Online

Refer an Account Online

Fill out the form below as completely as possible. Provide any additional information that may be useful in assisting us in collecting your account.

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Please note: fields marked with an asterisk (*) are required to process your submission. If you do not have information for one of these fields, type "N/A".

Your Information:

* Your Name:
Your Title:
* Company Name:
* Address 1:
Address 2:
* City:
* State:
* Zip Code:
* Phone Number:
Fax Number:
* E-mail Address:

Debtor Information:

* Name:
SSN:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone:
Last Known Employer:
Employer Phone:

Co-Debtor Information:

Name:
SSN:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone:
Last Known Employer:
Employer Phone:

Account Information:

By submitting an account for collection, you agree to the contingency fee agreement & disclosure statement we have for you on file. If you have not yet signed the contingency fee agreement & disclosure statement, a Vargo & Janson PC representative will contact you.

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This is an attempt to collect a debt by a debt collector. Any information obtained will be used for that purpose.

Account Ref. #:
* Principal Due:
Interest Due (if any):
Interest Calculated Through Date:
Interest Rate:
Misc. Amount Due (if any):
* Date of Last Payment:
* Charge-Off Date:
Type of Account: (Check all that apply)	Credit Card Medical Education - Tuition Education - Perkins Education - DULF Retail Personal NSF Check Auto Loan Commercial Judgment Purchased Debt Other
Comments:
Do you have a digital copy of the Proof of Debt? Proof of Debt File:	Yes No .pdf, .doc or .xls file format only. .pdf, .doc or .xls file format only. .pdf, .doc or .xls file format only.