COLLECTIVITY, LLC.

7842 Land O Lakes Blvd. #320, Land O Lakes, Florida, 34638.
TEL (813) 575-9962 * FAX (813)792-8609 * Email: mlevinson@collectivityllc.com
SHOULD YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO CONTACT US.

Debtor Information
• Legal Name*
• Your Acct #
• AKA/DBA
• Address*
  Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Contact*
• Position/Title
• Email
• Business Phone*
• Cell
• Home Phone
• Fax
• Legal Entity
  IndividualSole ProprietershipPartnershipCorporationLLCUnknown
• Basis of Claim*
  Merchandise Sold & DeliveredServices RenderedPromissory NoteContractNSF NoteStop Payment CheckBroken Promises of PaymentOther
• If Other Please Describe
• Total Owed $*
• Principal $*
• Interest $
• Rate
• Due Date of Original Debt*
  MM slash DD slash YYYY
• Date of Last Payment
  MM slash DD slash YYYY
• Amount of Last Payment $
• Personal Guarantor(s)*
  YesNoDon't Know
• *

  Guarantor(s) Name	Social Security #	Driver's License #

Your Experience
• Your Experience
  • Claim Disputed
  • Broken Promises
  • Phone Disconnected
  • Mail Returned
  • Partial Payments Stopped
  • Debtor Claims Business Closed
  • Claims to be Filing Bankruptcy
  • Claims to Have Sold the Business
  • Represented by Attorney
  • Other
• Attorney Name
• Other Experiences

Nature of Claim
• Nature of Claim
  • Merchandise
  • Services
  • Promissory Note
  • Dispute
  • NSF Check
  • Judgment
  • Other
• Other

• Terms

  YOUR AGENCY IS HEREBY AUTHORIZED TO PROCEED WITH IMMEDIATE COLLECTION OF THE ABOVE CLAIM. COMMISSIONS AT THE AGREED UPON RATE WILL BE CHARGED AND PAID TO AGENCY ON ACCOUNTS COLLECTED ( ACCOUNTS PAID DIRECTLY TO OUR FIRM AFTER PLACEMENT OR PAID DIRECTLY TO YOU AFTER PLACEMENT), AND ACCOUNTS SETTLED BY RETURN OF MERCHANDISE. AGENCY IS ALSO ENTITLED TO FULL FEE ON DISCOVERED PRIOR PAYMENTS OR MISAPPLIED PAYMENTS AFTER PLACEMENT. AGENCY AS OUR DULY AUTHORIZED AGENT, IS HEREBY AUTHORIZED TO ACCEPT PAYMENTS AND ENDORSE CHECKS, NOTES, MONEY ORDERS, OR DRAFTS ON OUR BEHALF, ACCEPT CREDIT CARDS, THE NET PROCEEDS OF WHICH AGENCY IS TO REMIT TO US. SPECIAL AUTHORIZATION IS REQUIRED TO FILE SUIT, COMPROMISE OR GRANT EXTENSION. THIS AGREEMENT IS MADE UNDER AND SHALL BE INTERPRETED, APPLIED, GOVERNED, CONSTRUED, AND ENFORCED UNDER AND PURSUANT TO THE LAWS OF THE STATE OF FLORIDA.

  
  STANDARD PRE-LEGAL RATES: COMMERCIAL CLAIMS 25% OF MONEY COLLECTED IF LESS THAN 1YEAR AND OVER $200; OTHERWISE 40% (1/2 RATE ON RETURN OF MERCHANDISE). CONSUMER CLAIMS 35% OF MONEY COLLECTED. RATES ALSO APPLY TO ANY PAYMENTS DISCOVERED BY CLIENT OR PROVEN TO CLIENT BY AGENCY AFTER PLACEMENT AS IF THE MONEY WAS COLLECTED DUE TO THE DIRECT EFFORTS OF THE AGENCY.

  
  STANDARD LEGAL RATES: 40% OF MONEY COLLECTED PLUS, IN ADVANCE, SUIT FEES AND COURT COSTS. ALL INTERNATIONAL CLAIMS, WHETHER PRE-LEGAL OR LEGAL ARE AT THE STANDARD 50% RATE. THE ABOVE RATES ARE SUBJECT TO CHANGE UPON PRIOR WRITTEN NOTICE BY THE AGENCY.
  BANKRUPTCY FILINGS OF PROOFS OF CLAIM: 40% OF ALL DIVIDENDS RECEIVED AFTER THE FILING OF THE PROOF OF CLAIM ON BEHALF OF CLIENT.

  CLIENTS WILL RECEIVE THEIR PORTION OF CLEARED FUNDS ON THE FIRST OF THE MONTH, FOLLOWING 30 DAYS OF FUNDS CLEARING

• Signed*
• Date*
  MM slash DD slash YYYY
• Print*
• Title*