Company Name:

Address:

City:

State:

Zip:

Amount Due:

Contact Name:

Phone:

Fax:

Email:

Acct # :

NSF Checks

Dispute Furnish Details

Remarks:

Company:

Contact Person:

Email:

Address:

City:

State:

Zip:

Phone:

Fax:

To expedite collection - we may request copies of all available documents
such as itemized statements - credit reports - purchase orders - signed
applications - original NSF checks - personal or corporate guarantees and/or
any pertinent correspondence substantiating this debt.

In addition, the Free Demand Service runs ten (10) days from the date this
form is submitted to EFS. Should you receive payment within the ten day
period, please notify us promptly. Otherwise, Immediate Service will
commence on the next business day following expiration of the Free Demand
Service.