Debt Collection Questionnaire

Please print out and then fill out the information on this form and fax it to our litigation department for the fastest results. Our fax# 1-617-328-5547

Your name____________________________

name and address of your business__________________________

______________________________________

tel #________________________________

e-mail #_____________________________

your name ___________________________

Nature of/type of your business?_________________________

Were there any written contracts between you and debtors stating the specific goods and/or services to be delivered; _____________________

If Yes please fax us a copy to 1-617-328-5547:

If there was no written contract, PLEASE GIVE US THE FOLLOWING INFORMATION.

date of oral contract.___________

name of person you made oral contract with __________

services you were to perform__________________

AMOUNT YOU WERE TO BE PAID_______________

Tell us about the debt:

Is it secured?_____

By what asset?__________________

Do you know the debtors checking acct# and bank? ____________________

Does the debtor own any real estate in Massachusetts?_______________ Where?_____________________

____________________________
Is the debtor claiming that it doesn’t owe the Money?______________

Is the debtor claiming that your work was unsatisfactory to him/it?______

If so, why?__________________________________________________

Tell us about the debtor:

Is debtor a corporation?___________________

In Massachusetts?__________________________

Exact name of Debtor’s business?_______________________

Address:__________________________________________

_________________________________________________

Name of person you dealt with___________________________

Debtor Tel #_____________

Please tell us what services you performed:_______________________

____________________________________________________________
Give all dates of goods and/or services rendered;

Start date_____________________________________________________________

Service performed_______________________Amount___________date______________

Please describe invoices/bills; requests for payments sent to debtors, stating the exact amounts owed by debtors;

Describe all payments made toward the debt by debtor:

Amount___________date______________

Date of last payment?_______Amount of last payment?_____________________

Current balance?_______________________________

Any other issues or information that you feel is relevant/important that we should know about this debt.

PLEASE ATTACH A COPY OF ALL INVOICES, CONTRACTS AND BALANCES YOU SENT TO DEBTOR with THIS FORM to fax# 1-617-328-5547

We also need copies of any correspondence from the debtors regarding the debts, including the last date of contact with debtors. fax to 1-617-328-5547. Please contact me with any questions regarding such information.

Thank You,

Hamaill Law Offices

36 Miller Stile Road

Quincy, MA 02169

(617) 773 - 6554

Fax (617) 328-5547

bhamill@covad.net

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Law Office of Bernard J. Hamill
36 Miller Stile Rd., Quincy, MA 02169
1-617-479-4300
Fax 1-617-328-5547
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