Law Offices of Corinne B. Rosner

Corinne B. Rosner P.A. is committed to providing you with a secure fast and efficient method of placing your delinquent accounts for collections. It is imperative that once you submit your files you either mail or fax all the documentation to support your claim. Please do not send originals unless they are requested. Furthermore, cease all communication including collections activity with the debtor.

Please enter all appropriate data in our placement form. Upon completion click the submit button. Our office will process your files immediately. In the event that you have multiple files that you want to submit online, you can email them in Excel or Word format to info@floridacollectionslaw.com

You can fax or mail all supporting documentation to (954) 424-0500.

Corinne B. Rosner P.A.
1776 North Pine Island Road, Suite 208
Plantation, Florida 33322

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Client Information
Company Name:
Contact:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

Debtor Information

Type of claim:

Account number:

Name of Account:

Responsible party:

Contact:

Address:

City:

State:

Zip:

Telephone:

Debtor History:
(please check all that apply)

mail returned
phone disconnected
disputed
check returned
other

Please include any additional information in the space provided below

Do you have a personal guarantor? Yes No

IF YES, please fill in GUARANTOR information below.

Name:

Social Security Number:

Address:

City:

State:

Zip:

Telephone:

Original amount due:

Current amount due:

Date of service:

Date of last activity:

Basis of claim:

Do you have a signed contact? Yes No

Please read before submitting
In submitting files for placement, the named client authorizes Corinne B. Rosner PA. to act as it’s legal council with respect to collections inclusive of litigation. Furthermore, client authorizes Corinne B. Rosner PA. to deposit all checks received into Corinne B. Rosner PA. Trust account. Corinne B. Rosner PA. will remit funds to client after deducting the agreed contingency fee on or before the 10^th day of the month following when said monies are collected. In addition, client agrees to remit to Corinne B. Rosner any monies received which were paid directly from the debtor less the agreed contingency fee.

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Privacy Statement: When accessing our Website, Corinne B. Rosner PA. will learn certain information about you during your visit. How we will handle information we learn about you depends upon what you do when visiting our site. Corinne B. Rosner PA. will not collect the email addresses of those who communicate with us via e-mail other than for the purpose of responding to requests.

Corinne B. Rosner PA. will not obtain personal identifying information about you when you visit our site, unless you choose to provide such information to us, nor will such information be sold or otherwise transferred to unaffiliated third parties without the approval of the user at the time of collection.