Submit a Consumer Account

Complete this form for debts belonging to individuals and incurred for personal, family, or household purposes.

Please note that fields marked with * are required.

Client Information

Company Name*

Address*

City*

Province*

Postal Code*

Phone*

Fax

Debtor Information

Account Number*

Account Name*

SIN*

Spouse Name

Address*

City*

Province*

Postal Code*

Home Phone 1*

Home Phone 2

Home Phone 3

Work Phone

Date of Birth*

Original Amount Due ($)*

Current Amount Due ($)*

Interest Due ($)*

Total Amount Due ($)*

Do you have a signed contract?* Yes No

Additional Information

Debtor History

Mail Returned
Phone Disconnected
Disputed
Check Returned
Inability to Pay
Other

Please Specify: