CREDITORS LIST

NAME___________________________________________________________________DATE_________________________

 CREDITOR'S NAME AND MAILING ADDRESS INCLUDING ZIP CODE
 CO DEBTOR IF ANY 

 DATE OF DEBT

 COLLECTION AGENCY NAME AND ADDRESS INCLUDING ZIP CODE

 COLLATERAL (IF SECURED) 

 DOLLAR AMOUNT

 ACCOUNT NUMBER___________________________

 

        
 ACCOUNT NUMBER___________________________        
 ACCOUNT NUMBER___________________________        
ACCOUNT NUMBER___________________________        
ACCOUNT NUMBER___________________________        

Copyright © Charles M Fugate 2000 all rights reserved

To be used for DEMPSEY, DEMPSEY & MOELLRING, P.C. use only