Capital Recovery Corporation

I just wanted to take a few minutes to let you know how I feel about your company. Ted Lansing Corporation has done business with Capital Recovery since about 1991 and it has been a pleasure. The staff at your company is always polite and helpful.

Ted Lansing Corp.

Richmond, VA

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Debtor Information

* Today's Date: * Claim Amount:

* Debtor:

* Address 1:

Address 2:

* City: * State: * Zip:

* Party to Contact:

* Account Number:

* Debtor's Phone Number:

* Debtor's Bank:

* Checks Returned:

* Dispute (Furnish Details Below):

Remarks:

Creditor Information

* Creditor:

Address 1:

Address 2:

City: State: Zip:

By:

Fax:

* E-mail:

Submitting This Claim

Please fax all supporting documentation to our Claims Processing Center at (770) 216-9353.

To send the form via fax:
From your browser's menu bar, click on File.
Then, print to your local printer.
Fax the form to us at (770) 216-9353.
Note: You can also print to your modem fax. Remember to close your internet connection if asked to do so. Then, retry the fax.

Upon submitting accounts, you authorize us to act as your agent for collection, contact your debtors, accept and endorse payments for deposit, and remit net proceeds to you.