Northern Financial Collection Services, Inc.

Assignment Form
If We Don't Collect, You Don't Pay!

Welcome and thank you for choosing Northern Financial Collection Services, as your agency for accounts receivable recovery. By submitting the assignment form, the authorized principal named below, has agreed upon the fee and costs associated with the collection of said account.

Please provide complete information.   *  Designated fields are required.

Creditor Information:
Creditor Name*
Address*
City*
State*
Zip*
Email
Phone*
Fax
Contact Title
Contact Name
Authorized By
Debtor Information:
Name*
Address*
City*
State*
Zip*
Phone
Work Phone
Date of Birth
SSN
Date of Service*
Spouse SSN
Date Last Service*
Date Last Charge
Amount* $
Interest $
Costs $
Total* $
Comments or
additional info

By submitting the assignment form, the authorized principal named above, has agreed upon the fee and costs associated with the collection of said account.


Northern Financial Collection Services, Inc.
33 Union St., Suite 5
P.O. Box 155
Weymouth, MA 02190		 Telephone: 781-331-2900
Toll free: 800-241-1982
Fax: 781-331-2909
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