List Account
We make placing accounts for collection easy and safe. Safety is accomplished by sending information encrypted on a secure server. If you would prefer to fax this form, use the forms supplied on our forms page, or click here. Just follow the directions below. You might find answers to questions in our client information sheet. If you still have questions, please contact us.

To obtain information about our competitive consumer and commercial contingency fees, please contact us and we will have a representive get back to you as soon as possible.

Existing Customers
Just fill out the form below and hit the send button. Someone will contact you soon.
New Customers
Just fill out the form below and hit the send button. Then go to our forms page and print our service agreement and fax to our office. Someone will contact you soon.
Responsible Party (Name 1)
First Name/MI
Last Name
Spouse (Name 2)
First Name/MI
Last Name
Contact Information
Street Address
State/City/Zip   
Phone Number
Notes & Additional information
Relatives, additional contact information, additional relevant information
Relative Relation
Phone Number
Relative Relation
Phone Number
Relative Relation
Phone Number
Other Details
Date Of Birth (i.e. mm/dd/yy) Name 1
 Name 2
Social Security Number (no dashes or spaces please) Name 1
Name 2
Drivers Licence Number/Issued by State Name 1 /
Name 2 /
Employment Information
Employer Name
Street Address
City/State/Zip
Phone Number
Spouses Employment Information
Employer Name
Street Address
City/State/Zip
Phone Number
Creditor Information
Account Number
Last Day of Service Date of Last Payment
Description of Services Date of Last Finance Charge
% of Financing Charge
Balance Owing Principle
 Finance Charge
Company Name/Email Address
Phone Number
I am Authorized to send this account for collection & agree to the terms listed below.

(Name of person sending this account for collection)
The above account is hereby assigned to Advantage Receivables Management, Inc., for collection. Any negotiable instrument received by them in payment of these accounts may be endorsed accordingly. A fee, based on negotiated contrat rate, will be charged by Advantage Receivables, Inc., upon any claims collected, settled with approval, paid direct or withdrawn during the process of collection. Payments mad direct to us will be reported to Advantage Receivables, Inc., immediately. All attorney fees, civil officer fees and court costs are to be advanced by Advantage Receivables Management, Inc. Any amount collected over and above the principle amount of the account (court costs, interest, attorney fees) are to be retained by Advantage Receivables Management, Inc. Adjustment or settlement of any claim is subject to our approval.

ALL CLAIMS HEREAFTER ASSIGNED ARE SUBJCT TO THE SAME TERMS UNLESS OTHERWISE AGREED.
P.O Box 994363 | 1135 Pine Street, Suite 202 | Redding, CA 96099-4363 | (530) 247-8081 | FAX (530) 247-8088