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International Claim Form

To be used by any creditor with a commercial claim against a debtor in a different country.

Please Note: In order to accept your claim we must have your phone number as ABC-Amega will not register any claim until it has been personally verified with your company by one of our representatives.

Required fields are in Bold.

Creditor/Client Information
ABC-Amega Client#:
(if you are already an ABC-Amega client)
Email Address:
Company Name:
Contact Name:
Address 1:
Address 2:
City/State/Postal Code:
Country:
Phone:
Fax:

Debtor Information
Company Name:
Owner/Principal:
Contact Name:
Address 1:
Address 2:
City/State/Postal Code:
Country:
Phone:
Fax:
Customer Account #:
Email:
Debtor's Bank:
Bank Phone:
Debtor is a:

Claim Information
Amount of Debt:
Currency Account is billed in:
Date of Oldest Invoice:	(mm/dd/yyyy)
Date of Last Payment:	(mm/dd/yyyy)
Terms of Sale:	Open Account
	Letter of Credit (L/C)
	Documents Against Acceptance (D/A)
	Documents Against Payment (D/P)
Did buyer receive goods?	Yes No
Did buyer accept Bill of Exchange?	Yes No

Did buyer receive Bill of Lading (title documents)?	Yes No

If buyer defaulted on Bill of Exchange, was a Protest issued by a Notary Public?	Yes No

If buyer received goods without accepting Bill of Exchange, was a demand made on the Negotiating Bank or the Shipping Agent for the value of the goods?	Yes No

Please mark all that apply:	Broken Promise
	Dishonored Checks
	Ignores Demands
	Personal Guaranty
	Unable to Contact
	Invalid Dispute
	Valid Dispute
Other (please specify):

I will be forwarding the following documents by:

Please mark all that apply:	Statement of Account
	Invoices
	Purchase Orders
	Dishonored Checks
	Correspondence
	Credit Report
	Arbitration Award
	Personal Guaranty
	Original Bill of Exchange
	Subrogation Agreement
Other (please specify):

Comments or Special Instructions

Please read the following before sending this form. The above account is provided for the purpose of collection efforts. ABC-Amega is authorized to deposit sums collected to its Trust Account and to select an attorney or agent to represent you in this matter, if required. You also certify that you have received, read and understood ABC-Amega's Fee Schedule and Fee Policies applicable to this claim.

	I have read and agree to the terms as described above.

International Claim Form

Creditor/Client Information

Debtor Information

Claim Information