Claim Submissions

Name

Contact Info

Account Open Date

Charge Off Date

Forwarder Number

New Forwarder?

Name Address Address Continued City State Zip Phone Fax Contact Person

Opposing Party Name

Opposing Party Address

Opposing Party Address Continued

Opposing Party City

Opposing Party State

Opposing Party Zip

Creditor Name & Phone

Creditor Address

Creditor Address Continued & City

Creditor State & Zip

Fee Arrangement

Lloyd Attorney

Subject

Claim Description

Current Principal

Current Interest

Interest Rate

Total Balance

File Number

Standard BB&T PNC Premium