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<title>Submit Your Claim Online!</title>
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<td><img name="sidebar2_15" src="images/sidebar2_15.jpg" width="109" height="148"></td>
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<td width="50" rowspan="2" bgcolor="white"><img height="30" width="20" src="images/spacer.gif"></td>
<td colspan="2" align="center" valign="middle" height="147"><img height="147" width="401" src="images/opener.gif"></td>
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<tr height="477">
<td height="477" colspan="2" align="left" valign="top">
<div align="left">
<body>
<form action="aspmail.asp" method="post">
<input type="hidden" name="recipient" value="[email protected]">
<input type="hidden" value="REMOTE_HOST,HTTP_USER_AGENT" name="env_report"><input type="hidden" value="http://www.biehlcollects.com/index.html" name="redirect">
<table border="0" cellpadding="0" cellspacing="0" width="401" bgcolor="white" align="left">
<tr height="13">
<td height="13" colspan="4">
<center>
<h3>To be used by U.S. Creditors with<br>
commercial claims against U.S. Debtors</h3>
</center>
<p>Please note: Unless you are an existing client with a valid Biehl & Biehl Collection Client # we will not register any claim until it has been personally verified by a representative of your company.</p>
<p><font size="1">(The first claim submitted to Biehl & Biehl through our web site will be verified by phone. Your company will be issued a Client ID number for future claims. The issuance of this I.D. number does not guarantee complete security. Therefore, should you believe that any third party has gained access to this I.D. number, please inform Biehl & Biehl Collections immediately.) </font></td>
</tr>
<tr height="13">
<td height="13" colspan="4">
<h3>Please Provide the Following Information</h3>
<h3>Client Information</h3>
</td>
</tr>
<tr height="35">
<td width="401" height="35" align="left" valign="top">Biehl & Biehl Client #:<br>
</td>
<td height="35" colspan="3"><input type="text" name="Client Number" size="24"><br>
(If already a Biehl & Biehl client.)</td>
</tr>
<tr height="35">
<td width="401" height="35" align="left" valign="top">Company Name:</td>
<td height="35" colspan="3"><input type="text" name="Company Name" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" align="left" valign="top">Address:</td>
<td height="35" colspan="3"><input type="text" name="Client Address" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" align="left" valign="top">City/State/Zip:</td>
<td height="35" colspan="3"><input type="text" name="City State Zip" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" align="left" valign="top">Who referred<br>
you to us?</td>
<td height="35" colspan="3"><input type="text" name="Who Referred You" size="45"></td>
</tr>
<tr height="40">
<td width="401" height="40" align="center" valign="bottom">Phone:<br>
<input type="text" name="Client Phone" size="12"></td>
<td width="100" height="40" align="center" valign="bottom">Fax:<br>
<input type="text" name="Client Fax" size="12"></td>
<td height="40" width="160" align="center" valign="bottom">E-Mail:<br>
<input type="text" name="Client E-Mail" size="20"></td>
<td height="40" bgcolor="white" valign="bottom"></td>
</tr>
<tr height="40">
<td height="40" colspan="4" align="left" valign="middle">
<h3><br>
Debtor Information</h3>
</td>
</tr>
<tr height="35">
<td width="401" height="35" valign="top">Company Name:</td>
<td height="35" colspan="3" valign="top"><input type="text" name="Company Name" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" valign="top">Owner/Principal:</td>
<td height="35" colspan="3" valign="top"><input type="text" name="Owner/Principal" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" valign="top">Contact Name:</td>
<td height="35" colspan="3" valign="top"><input type="text" name="Contact Name" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" valign="top">Address:</td>
<td height="35" colspan="3" valign="top"><input type="text" name="Debtor Address" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" valign="top">City/State/Zip:</td>
<td height="35" colspan="3" valign="top"><input type="text" name="DebtorCityStateZip" size="45"></td>
</tr>
<tr height="35">
<td width="401" height="35" valign="top" align="center">Phone:<br>
<input type="text" name="Debtor Phone" size="12"></td>
<td width="100" height="35" valign="top" align="center">Fax:<br>
<input type="text" name="Debtor Fax" size="12"></td>
<td height="35" valign="top" width="160" align="center">E-Mail:<br>
<input type="text" name="Debtor Email" size="20"></td>
<td height="35" valign="top" align="center">Customer#:<br>
<input type="text" name="Debtor Customer Number" size="20"></td>
</tr>
<tr height="50" valign="top">
<td width="401" height="50" valign="middle"><br>
<br>
Debtor's Bank:</td>
<td height="50" colspan="2" valign="bottom"><input type="text" name="Debtor Bank" size="34"></td>
<td height="50" valign="bottom" align="center">Bank Phone:<input type="text" name="Debtor Bank Phone" size="16"></td>
</tr>
<tr height="50">
<td width="401" height="50" valign="middle">Debtor is a:</td>
<td width="100" height="50" valign="middle"><input type="radio" value="corporation" name="debtor is" tabindex="4"> <label>Corporation</label></td>
<td height="50" width="160" valign="middle"><input type="radio" value="partnership" name="debtor is" tabindex="4"><label>Partnership</label></td>
<td height="50" valign="middle"><input type="radio" value="sole proprietorship" name="debtor is" tabindex="4"> <label>Sole Proprietorship</label></td>
</tr>
<tr height="35">
<td height="35" valign="top" align="center" colspan="2">Amount of Debt:<br>
<input type="text" name="Amount Of Debt" size="12"></td>
<td height="35" width="160" align="center" valign="top">Date of oldest invoice:<br>
<input type="text" name="Date Oldest Invoice" size="12"></td>
<td height="35" valign="top" align="center">Date of last payment:<br>
<input type="text" name="Last Payment" size="12"></td>
</tr>
<tr height="55" align="left" valign="middle">
<td height="55" valign="middle" colspan="2" align="center">Did buyer receive goods?:<br>
<input type="radio" value="Yes" name="receive goods" tabindex="4"><label>Yes</label> <input type="radio" value="no" name="receive goods" tabindex="4"><label>No</label></td>
<td height="55" colspan="2" align="center" valign="middle">Did buyer receive invoice?:<br>
<input type="radio" value="yes" name="receive invoice" tabindex="4"><label>Yes</label> <input type="radio" value="no" name="receive invoice" tabindex="4"><label>No</label></td>
</tr>
<tr height="40">
<td width="401" height="40" valign="top" bgcolor="white"></td>
<td height="40" colspan="2" valign="bottom">Please mark all that apply:</td>
<td height="40"><font color="white"><select name="All That Apply" size="3" multiple>
<option value="one">NSF Checks
<option value="two">Ignores Demands
<option value="three">Unable to Contact
<option value="fourth">Valid Dispute
<option value="five">Invalid Dispute
<option value="six">Broken Promises
</select></font></td>
</tr>
<tr height="40">
<td width="401" height="40" valign="top" bgcolor="white"></td>
<td height="40" colspan="3" valign="top"><font size="2">(To select more than one: press CONTROL,or COMMAND for Mac, click with mouse)</font></td>
</tr>
<tr height="40">
<td width="401" height="40" valign="top" bgcolor="white"></td>
<td width="100" height="40" valign="top">Others:<br>
(Please Specify)</td>
<td height="40" colspan="2"><input type="text" name="Debtor Specify Others" size="45"></td>
</tr>
<tr height="40">
<td width="401" height="40" valign="top" bgcolor="white"></td>
<td height="40" colspan="2" valign="bottom">I will be forwarding the following documents:</td>
<td height="40" bgcolor="white"><select name="Documents" size="3" multiple>
<option value="one">None
<option value="two">Statement of Account
<option value="three">Invoices
<option value="fourth">Purchase Orders
<option value="five">Dishonored Checks
<option value="six">Correspondence
<option value="seven">Credit Report
<option value="eight">Arbitration Award
<option value="nine">Personal Guaranty
<option value="ten">Original Bill of Exchange
<option value="elevan">Other
</select></td>
</tr>
<tr height="40">
<td width="401" height="40" valign="top" bgcolor="white"></td>
<td height="40" colspan="3" valign="top"><font size="2">(To select more than one: press CONTROL,or COMMAND for Mac, click with mouse)</font></td>
</tr>
<tr height="22">
<td width="401" height="22" bgcolor="white"></td>
<td height="22" colspan="3" valign="bottom">Comments or Special Instructions:</td>
</tr>
<tr height="22">
<td width="401" height="22" bgcolor="white"></td>
<td height="22" colspan="3"><textarea name="Comments" cols="50" rows="4" wrap="physical"></textarea></td>
</tr>
<tr height="22">
<td height="22" colspan="4"></td>
</tr>
<tr height="22">
<td height="22" colspan="4">
<center>
<h3>Please read the following before sending this form.</h3>
</center>
<div align="left">
<p><font size="2">The above account is provided for the purpose of collection efforts. Biehl & Biehl Collection is authorized to deposit sums collected to its Trust Account and to select an attorney or agent to represent you in this matter, if required. You also certify that you have received, read and understood Biehl & Biehl Collection Fee Schedule applicable to this claim. </font></div>
</td>
</tr>
<tr height="50">
<td width="401" height="50" bgcolor="white"></td>
<td width="100" height="50" align="center" valign="bottom">
<input type="submit" name="mail" value="Please submit your claim"></td>
<td width="160" height="50" align="center" bgcolor="white" valign="bottom"><input type="reset"></td>
<td height="50" bgcolor="white" align="center" valign="bottom"></td>
</tr>
<tr height="22">
<td height="22" bgcolor="white" colspan="4">
<center>
<a href="index.html">Home</a> | <a href="contact.html">Contact Us</a> | <a href="overview.html">Corporate Overview</a> | <a href="services.html">Collection Services</a> | <a href="submit_claim.html">Submit a Claim</a> | <a href="employ_opps.html">Employment </a></center>
</td>
</tr>
</table>
</form>
</body>
</html>