Date Claim Submitted: __________________
Outstanding Balance Due: ________________
Name of Business: ________________________________________________________
Corporate Owner/Proprietors: _______________________________________________
[ ] Corporation [ ] General Partnership [ ] Sole Proprietor [ ] LLC Limited Partnership
Business Address: ________________________________________________________
Street City State Zip Code
Phone: ___________________________
Contacts: _____________________________
Billing Address: __________________________________________________________
Street City State Zip Code
Phone: ___________________________
Contacts: _____________________________
Alternate Address/contacts: _________________________________________________
_________________________________________________________
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Enclosures:
[ ] Master Agreement [ ] Copies of Payment/Checks
[ ] Change Order (s) [ ] Copy of Ad (s)
[ ] Invoices [ ] Copy of Proof (s)
[ ] Statement of Account [ ] Correspondence
[ ] Payment History [ ] Other
[ ] Proof of Mailing/Delivery
Other Information: _________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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