THOMAS GEORGE ASSOCIATES
P.O. Box 30 / 10 Larkfield Road E. Northport, NY 11731
Phone (631) 261-8800 / Fax (631) 261-8896


Consumer/Commercial Recovery & Billing Form

	Product Purchase
	Services Rendered
	Contractual Agreement
	Other
Client Name		Date
Assigned By		Phone

Address

Responsible Party Information

Name		Account Number
Address
City, State, Zip
Phone		Total Balance Owed $
Comments

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Submitter's Email Address