ARS Placing Accounts

Online Account Listing

Please print before submitting if you wish to retain a hard copy of this file.

Your Listing Information: First Name Last Name Business Address City State Zip Phone Fax E-mail     Debtor 1 Information:   First Name Last Name Spouse First Name Spouse Last Name Address City State Zip Phone Social Security # Type of Account: Select One Pre-collection Health Care Billing Full Collection Amount Debtor Account # Debtor's Employer Date of Last Payment Date of Delinquency Check if mail has been returned Check if account is disputed Other helpful information   Jump to end to submit Debtor 2 Information: First Name Last Name Spouse First Name Spouse Last Name Address City State Zip Phone Social Security # Type of Account: Select One Pre-collection Health Care Billing Full Collection Amount Debtor Account # Debtor's Employer Date of Last Payment Date of Delinquency Check if mail has been returned Check if account is disputed Other helpful information   Jump to end to submit Debtor 3 Information: First Name Last Name Spouse First Name Spouse Last Name Address City State Zip Phone Social Security # Type of Account: Select One Pre-collection Health Care Billing Full Collection Amount Debtor Account # Debtor's Employer Date of Last Payment Date of Delinquency Check if mail has been returned Check if account is disputed Other helpful information   Jump to end to submit Debtor 4 Information: First Name Last Name Spouse First Name Spouse Last Name Address City State Zip Phone Social Security # Type of Account: Select One Pre-collection Health Care Billing Full Collection Amount Debtor Account # Debtor's Employer Date of Last Payment Date of Delinquency Check if mail has been returned Check if account is disputed Other helpful information I hereby assign and transfer to Accelerated Receivables Solutions, a Nebraska corporation, our account and claim against the debtor shown above in the amount shown above, plus interest, with full authority to take whatever steps necessary to collect and satisfy the same. The undersigned warrants that the account hereby assigned is a valid debt now fully due and owing to the undersigned from the debtor named, that no payments have been made on the account except as stated in said statement and that there is no just counterclaim or offset against the same. I understand that accounts sent for collection are subject to the regular rates and conditions of Accelerated Receivables Solutions.