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Judgment Claim Form
Claim Placement Form

Complete the Form below and submit.
You will receive immediate verification of your claim placement.

If you experience difficulty submitting the claim, contact Mary Mausbach mmausbach@andc.com or 800-456-5770.

* Required fields

Subject:

Creditor Name: *

Contact Name: *

Address: *

City, State, Zip: *

Country:

Phone: *

Fax:

E-Mail: *

Debtor Information-Claim 1

Debtor Contact Name: *

Debtor Address: *

City, State, Zip: *

Country:

Debtor Phone:

Debtor Fax:

Debtor E-mail:

Debtor Cell Phone:

Debtor Social Security #:
(Consumer Claims only)

First Date of Delinquency:*
(00/00/0000)

Claim Amount: (USD) *

Attach judgment: (PDF Format)

Tell us about your case so we can conduct a case evaluation and propose a fee:

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