COMMERCIAL COLLECTION SERVICE, INC.
120 4th Street
Suite 2-220
Petaluma, California 94952
Ph. (877)-578-6510
Fax (877) 445-6042
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Collection Assignment Form
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Client’s Debtor Account Number: ______________
Debtor’s Business Name: ________________________________________________________________
Principal(s) / Owner(s): _________________________________________________________________
Business Address: _____________________________________________________________________
City: __________________________ State:______________ Zip:__________
Telephone: ___________________ Fax:_____________________
Home Address: _______________________________________________________________________
City: _________________________________ State:______________ Zip:_________ ________
Home Phone: ___________________ Cell Phone:_____________________
Type of Entity:
Corporation _____ Individual or Sole Owner ____
Partnership _____ Other (explain):_____________________________
Balance Due: _____________________
Date of Last Charge: ______________ Date of Last Payment:_____________
The Following Items are Attached:
Credit Application ____ Personal Guaranty _____ Statement ____
Invoices _____ Original Bad Checks ______ Correspondence _____
Additional Information: _______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
The undersigned creditor (Client) assigns the account listed above to Commercial Collection Service, Inc.,
(CCS) for collection. If Client and CCS have executed an Account Collection Agreement (ACA), the terms of
the ACA will govern this assignment. If Client and CCS haven’t executed an ACA, Client agrees that CCS shall
be entitled to a commission on any recovery on this account, whether the debtor pays CCS, pays Client,
receives credit for services rendered or returns merchandise to Client. Client shall advice CCS promptly when
it receives funds, goods, and services concerning this account. If Client fails to pay CCS its commission, CCS
shall have the right to offset its commission against any money owed by CCS to Client whether or not related
to this account. Client authorizes CCS to endorse negotiable instruments concerning this account. If suit is filed
against the debtor or other third party concerning this account, CCS will deduct any court costs advanced and
retain all interest and legal fees collected. In the event of a dispute between Client and CCS concerning this
assignment, the contract shall be deemed executed and performed at Santa Rosa, California, venue shall be
in Sonoma County, and the prevailing party shall be entitled to attorney’s fees in addition to all other damages
and costs.
Name of Creditor______________________________________________ Phone __________________
Address_____________________________________________________ Fax ____________________
Signature___________________________________ Title_____________ Date____________________