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Collection Authority Form

My/Our email address is:  *

Debtors Details...(if not applicable use n/a)

Debtors Full Name: 
D.O.B: 
Trading Name: 
Contact Name: 
Debtors Address: 
Debtors P.O. Box: 
Debtors Telephone: 
Debtors Mobile: 
Debtors Fax: 
Debtors Email Address: 
Debtors Customer No: 
Do you have a signed credit application form?  yes   no  
Do you have the debt recovery clause?  yes   no  

Amount of debt? 

Collection costs can only be added to the debt if you have a signed agreement with the debtor or the debtor is aware of extra costs at the time the job is done if not paid on time. YOU CANNOT ADD COLLECTION COSTS TO THE INVOICE AFTER THE WORK HAS BEEN COMPLETED

Commission to be added to debt?  yes   no  
Collection costs to be added?  yes   no  
Can you post/fax/email copy of statements or invoices to us?  yes   no  
Amount owing? 
Date (as per statement): 
Since Paid? 
Date: 
Balance owing: 
Date: 
Do you require - Debt Recovery?  yes   no  
Do you require - Tracing?  yes   no  
Do you require - Agents Visit?  yes   no  

Do you require - Legal Action?  yes   no  
Do you require - Legal Action?  yes   no  

Client Authorisation Part 1...(if not applicable use n/a)

Client Name: 
Contract: 
Client No: 
Date: 
Collection Officer: 
Special Comments: 

Client Authorisation Part 2 (type your name in the box)...

I/We authorise Law Debt Collection to act as our agents in the recovery of all debt collection matters and agree to pay all commission and costs in accordance with the Terms Of Engagement completed 
Name of person completing this form: 
Email of person completing this form: 
Please enter the verification code in the image above *