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For more information and rates, please contact your regional sales manager @ (800)935-5966 or our Las Vegas Collection Office @ (866)873-5966 ext. 5070.

YOUR INFORMATION

Creditor Number*: or Subscriber Number*:
Company Name*:
Contact Name*:
Address**:
City**: State**:  Zip**:
Phone**:     Fax**:
Email:

*  required fields
** required fields if you do not provide creditor or subscriber number

DEBTOR INFORMATION

Debtor Name*:
Contact Name:
Street Address*:
City, State, Zip Code*: , -
Outside USA or Canada Address*:
Phone:
Fax:
Debtor Account No:
Business Classification: Corporation Public Company Limited Liability Corp. Partnership Proprietorship
Unknown

All information except the last 4 digits of your 9 digit ZIP+4 code is required to process your claim.

CLAIM INFORMATION

Collection Program: Demand Collection
Soft Collection   A/R Management Letter
Associate Attorney
Prestige Letter
This collection program is restricted to Lyon Mercantile Group Ltd. subscribers only.
It is understood there will be no collection charge on payment reported to Lyon within ten days from the date of the Prestige Letter. If not paid in full within the ten day period, Lyon is authorized to proceed further with the collection of the account or the unpaid balance in the event that a partial payment is received.
Type of Debt: Invoice NSF Check
Current Balance Due:
ex. 1234.56
This amount should include any interest due. A signed credit application or contract from the debtor is necessary to include this interest.
Do you have authorization to include 'Collection Fees' in the collection process?  No    Yes

INVOICES

Note: If no date is entered, the contingent fee will be 33.33%

Please enter the invoice information below (in order of the earliest invoice). If there are more than 10 invoices please fax the copies to our Las Vegas Office at (702) 838-6109. Or, after you click "Submit", you will have an option to attach an electronic copy of your claim backup (invoices, statements etc.).

Invoice Number Invoice Date
mm/dd/yyyy		 Invoice Amount
ex. 1234.56

Please enter any comments that pertain to this claim:

Note: By submitting this form, you are authorizing Lyon Collection Services, Inc., to pursue your claim in accordance to the specified collection program. You are also acknowledging that you are familiar with Lyon's Collection Fees and will pay the fee on claims that are collected. If you would like to view Lyon's Standard Contingent Collection Fees, click here.