Name: Collect My Debt Ltd
Address: 265-269 Kingston Road, Wimbledon, London, SW19 3NW
Telephone: 0800-612-5161

If you cannot confirm the current details for the person in question, the likelihood of success is significantly reduced Please also complete a Trace Investigation Instruction form
Defaulter Details*
Forename Surname D.O.B. Email: Tel No:
Address:*
Street Address Address Line 2 City County Postal Code Country
Amount Overdue:*
Please attach supportive information such as Invoice, Statement of Arrears, Agreements etc.
Drop files here or
Accepted file types: jpg, gif, png, pdf, jpeg.
Type of Business*
- Limited Company
- Sole Trader
- Partnership
- Individual
Trading As:
Additional Defaulter Information
Instructing Client Details
Company name:
Your Name:*
First Last
Your contact details:
Tel No: Mobile No: Email Address:
Invoice Address:*
Street Address Address Line 2 City County Postal Code Country
Remittance Details:*
Bank Name: Bank Address: Account No: Sort Code Reference:
Notes: Payments remitted to you during the first week of each calendar month. Percentage commission of debt monies recovered (15% plus VAT - Under 5K) (8% plus VAT - 5K to 10K) ( 5% plus VAT - Over 10K)
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- I agree to the Terms and Conditions
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Signature:*
Please sign below to Instruct us and accept our Terms & Conditions - you can sign this using either a mobile / tablet touch screen or PC Mouse / laptop mouse pad
Date of Instruction
Date Format: DD slash MM slash YYYY

If you cannot confirm the current details for the person in question, the likelihood of success is significantly reduced Please also complete a Trace Investigation Instruction form

Instructing Client Details