(308) 381 1423 & 1-888-603-1423

Collection Request Form

Please fill out and submit this form. If you prefer to print and mail it, send to: General Collection Co., PO Box 1423, Grand Island, NE 68802, Fax 308-381-0219.

Your Contact Information

Company/Business Name *
Contact Person *
Contact Phone # *
E-mail *
Address *
Address 2
City *
State *
Zip *

Debtor Information:

Debtor's Number *
Debtor's Full Name *
Spouse Name
Address *
Address 2
City *
State *
Zip *
Mail Ret'd *
Employer
Home Phone # *
Spouse Employer
Date of Last Charge *
Date of Last Pay *
Amount *
Interest *
Total Due *
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