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Claim analysis form Provide us with information about the debt owed using the claims analysis form on this page. First, we will ascertain whether representing you would conflict with the representation of one of our existing clients. We will contact you to discuss some of the details of your legal matter so we can make that determination. If we can represent you, our representation will begin when we are in agreement as to the terms of representation and those terms are put in writing. Only then will you become our client and share confidential information with us about your legal matter. Until we have accepted you as our client, any information you share with us using this form will not be privileged or confidential. That being so, please do not send to us by use of this form or e-mail any information that is confidential. More Information In addition to completing this form, please send us by fax, email or regular mail, copies of all pertinent documents such as invoices, statements, returned checks, correspondence, etc. Claim Details Enter as much detail as you can about the debt you are seeking to collect in the form below. We will review the claim and correspond with you shortly as to how we may be of assistance. Are you a pre-existing customer?: yes no *Your First Name: *Your Last Name: Your Email: *Your Daytime Phone: Your Mobile Phone: Your Fax: The Name of Your Company: If you are submitting the claim on behalf of a company, provide its name. Address Line 1: Address Line 2: City: State/Province: ZIP/Postal Code: Service Requested: Facts About Your Claim: I have a written contract which shows the amount due. I am seeking payment for a loan for which I have no documents. I am seeking payment for work/services I performed. I am seeking payment for goods I delivered. To Whom Is the Debt Owed: If the debt is not owed to you personally, to whom is it owed? Debtor's full name: What is the full name of the company or person who owes the debt? Debtor's address 1: Debtor's address 2: Debtor's City: Debtor's State: Debtor's Zip Code: Current Balance Owed: Your Account or Reference Number: Describe what is owed to you and why: Please provide as much detail as you can. Debtor History: No response Mail returned Check returned Claims inability to pay Disputed Phone disconnected Choose all that apply. Debtor's employer (last known): Debtor's Assets: If you believe the debtor has assets that can be executed on, describe them here. Submit Your Message: |
Office Hours: Appointments only Monday through Friday 9 am to 5 pm Saturday and Sunday Closed Phone 845-264-5271 Fax 845-231-6080 contact@tmurphylawfirm.com 33 Henry St Suite 4 Beacon, NY 12508 |