Please use the Collection Referral Form below to submit a claim.

 

NOTE:  Information received via this form is considered private and sensitive, and is held in strict confidence by Wilhelm Law Firm, PLLC.

 

Debtor's Information

Name (Corp, DBA):

Street Address:

Address (cont.):

City:
State:
Zip:
Phone:
Fax:
E-mail:
Amount Due:

Account #:
Debtor SS/Tax ID:
Services Requested:

 

 

Creditor's Information

Name:

Contact:
Address:
Address (cont.)
City:
State:
ZIP:
Phone:
FAX:
Email:

 

 

Forwarder's Information

Name:

Contact:

Street Address:

Address (cont.):

City:
State:
ZIP:
Phone:
Email:

 

 

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