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Submit a Claim

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* Required

New or Existing Client *
Current/Existing Client
New Client

Your Company Name *

ABC-Amega Client # (type N/A if not applicable) *

If you are submitting as an agent for another creditor, please list the creditor's name and address below:

Title

First Name *

Last Name *

Email Address *

Work Address *

City *

State *

Zipcode/Postcode *

Country *

Work Phone Number *

Debtor Company Name *

Customer Account #

Debtor Contact Name *

Debtor Address *

Debtor City *

Debtor State *

Debtor Zipcode/Postcode *

Debtor Country *

Debtor Phone *

Debtor Email Address

Debtor's Bank

Debtor's Bank Phone

Amount of Claim/Debt *

Currency *

Interest

Date of Oldest Invoice

Date of Last Payment

Terms of Sale (select all that apply):
Documents against Acceptance (D/A)
Documents against Payment (D/P)
Open Account (O/A)
Letter of Credit (L/C)
Others

Debtor (select all that apply):
Accepted B/E
Received B/L
Received goods/services

Did the debtor dispute the quality of the goods/services?
Yes
No

Is the debtor still in business?
Yes
No
Unable to Verify

Does the Sales Contract contain an arbitration clause?
Yes
No

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Comments or Special Instructions:

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Buffalo, New York 14204-1963 USA

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