Name *

First Name

Last Name

Phone *

(###)

###

####

Business Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization *

Do you authorize: a) CannaBIZ Collects to act as your collection agent to mange the claim(s) you are submitting and agree that claims cannot be reversed once they are submitted. b) Any accounts that were actually paid prior to placement will be subject to a $500/claim finder's fee. c) Cannabiz retains the authority to disclose pertinent claim information to third parties, encompassing credit bureaus and credit agencies, including any prior claims previously submitted by the Client. Cannabiz commits to ensuring the anonymization of Client data, safeguarding the Client's identity remains confidential and unidentifiable as the primary source of said data.

Yes

Have you submitted this debt to another agency or attorney already? *

Yes

No

How old is this claim? *

Less than one year

More than one year

Debtor History *

No Response

Check Returned

Disputed

Mail Returned

Claims Inability to Pay

Phone Disconnected

Other

Debtor's Name *

First Name

Last Name

Debtor's Phone *

(###)

###

####

Debtor's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country