General Authorization Form printable pdf download

GENERAL AUTHORIZATION FORM

& PPL MEMBER AFFIDAVIT FOR

REQUESTED COLLECTION / DEMAND LETTER(S)

TO: De Beaubien Knight Simmons Mantzaris & Neal

FAX #: 407-420-2092

P. O. Box 87

Orlando, FL 32802

FROM: ________________________________

MEMBERSHIP # ________________________

(full name of PPL member)

INTAKE # ______________________________

===============================================================

PLEASE PREPARE and mail a debt collection letter on my behalf to the following named individual or

business (circle one), based upon the information provided below:

1) Full Name of Debtor: ________________________________________________________

2) (If debtor is a business) Full Name of the Debtor’s Owner or Representative, and applicable

title (i.e., sole proprietor, president, treasurer, agent, associate):

___________________________________________________________________________

(Letter will not be set without the full name/title of owner or representative)

3) Debtor’s Address: ___________________________________________________________

City/State/Zip: ______________________________________________________________

4) Total Amount of Debt: $____________________

5) The total amount of this debt as specified in #4 above is comprised of the following sums

(i.e., principal, interest, costs, returned-check fees):

___________________________________________________________________________

(All figures must precisely total the amount shown in # 4, above)

6) _____ (Check if applicable). I wish for this debt collection letter to be mailed via certified

mail in order to confirm receipt, and I have enclosed a check or money order in the amount of

$8.00 for the cost of same.

(**NOTE: If your debt/claim is based on a writing of any kind (i.e., an agreement, contract, invoice,

receipt, note, check, or other), then you must include also a complete legible copy of such writing(s).

Include also a complete legible copy of any other documents that lend support to your claim, including any

prior written demand(s). DO NOT SEND ORIGINALS.)

I CERTIFY THAT I, _____________________ (Name of Member) have previously made formal

written demand(s) for payment upon the above-named debtor, a copy(ies) of which is/are enclosed

herewith, and that such demand(s) was/were unsuccessful; that I am providing a legible copy of all

documents which support this claim; that this account receivable has not been assigned or sold to any

third party and; that I have not received any written notice from the debtor or his/her/its attorney

advising me or my business that said debtor has filed for bankruptcy protection. Further, I hereby

ackowledge that all of the information provided herein may be provided to the debtor upon request if

said debtor disputes this debt.

_____________________________________________

______________________________

Signature of PPL Member or Authorized Representative

Date

General Authorization Form

Related Articles

Related forms

Related Categories