MAILING ADDRESS

AG Adjustments
PO Box 9090
Melville, NY 11747

TELEPHONE

Phone: (631) 425-8800
Fax: (631) 425-8808
Toll Free: (888) 496-1600

Placement Form - Single claim

Individual claims can be submitted online using the form below. If you have any questions on claim submission please be sure to contact us at (631) 719-8028.

(Fields marked with * are required)

Today's Date:	05/18/2012
Please Accept This Account For:
Company or Trade Style: *
Officer or Owner:
Street Address: *
City: *
State: *
Zip: *
Telephone:
Fax:
E-mail (debtor):
Corporate Status:
Balance Due: *
Date of Oldest Invoice:
Assigned by (name of creditor): *
Your name: *
Title:
Telephone Number:
Street Address:
City:
State:
Zip:
E-mail (client):
Creditor:
Reference Number:
Comments:

Please submit any contracts, notes, returned checks, itemized statements or other papers that are needed. When necessary, you are authorized to forward this account, under bond, to a commercial attorney.
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