800-968-2733
DUE TO CONSTRUCTION our office will not be able to have in person visitors from SEPTEMBER 2023 until SPRING OF 2024. During this time we will not be accepting payments in person. We apologize for any inconvenience. Please call our office for any questions.
SUBMIT NEW BUSINESS

CBM Client Information

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New CBM clients please fill in all client fields. Existing CBM clients only need to fill in Client Name and Collection Type.
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Client Name
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Phone Number
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Email
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Client Account Number:
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Authorized By
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Collection Type
  • - select a option -
  • Standard Collection
  • Precollect
- select a option -
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Debtor Information

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First Name
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Last Name
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Name Of Responsible Party (if any)
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Know Account Number?
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Debtor Account Number
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Date Of Service
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Charge-Off Date
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Know Date of Last Payment?
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Date Of Last Payment
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Beginning Balance From DOS
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Accrued Interest
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Fees and Penalties
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Payments or Adjustments
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Current Balance Placed For Collections
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Debtor Phone
Phone Number
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Responsible Party Phone (if any)
Phone Number
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Know Address of Debtor?
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Address
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Address 2
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City
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State
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Zip Code
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Know SSN of Debtor?
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Social Security Number
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SSN of Responsible Party (if any)
Social Security Number
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Know DOB of Debtor?
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Date Of Birth
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Responsible Party DOB
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Place Of Employment
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Place Of Employment Phone
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Spouse Information

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First Name
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Last Name
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Date Of Birth
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Social Security Number
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Phone Number
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Is Spouse Responsible Party?
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Additional Information

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New Business Listing Sheets

Print form in Microsoft Word. Fill out and fax to 989-631-0705

» New business listing sheet

HIPPA Compliance

» Business Associate Agreement