National Bond and Collection Associates  (World Wide Web USER)              			
				Pennsylvania:
		Phone: 1-800-326-9808  FAX:  1-717-287-6063
				
				Florida:
		Phone: 1-800-351-9789  Retail Fax: 1-813-799-1941
			
		Priority Fax - Commercial Placments Only:
				1-813-799-1176
			Check here ______ if you would like to have us call and 
discuss your collection problems.  In submitting this list, the credit grantor gives
assurance to the agent, that it (or he/she), has complied with the disclosure
and other provisions contained in Truth in Lending.
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Debtor's No. _________________________ Debtor's Full Name ____________________
Spouse_______________________________________________ Phone __________________
Address _______________________________________________ Zip __________________
Debtor's SSN __________________________ Spouse's SSN _________________________
Employer ___________________________________ Work Phone ______________________
Spouse Employer ______________________________________ Acct Disputed:  Y or N 
     Date of Last Charge __________ Date of Last Pay __________ Mail Ret'd: Y or N
Additional Information ______________________________ 
Amount $___________________________________________________________________ 
Interest $ _________________________________________________________________ 
Total Due $ _______________
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Debtor's No. _________________________ Debtor's Full Name ____________________
Spouse_______________________________________________ Phone __________________
Address _______________________________________________ Zip __________________
Debtor's SSN __________________________ Spouse's SSN _________________________
Employer ___________________________________ Work Phone ______________________
Spouse Employer ______________________________________ Acct Disputed:  Y or N 
     Date of Last Charge __________ Date of Last Pay __________ Mail Ret'd: Y or N
Additional Information ______________________________ 
Amount $___________________________________________________________________ 
Interest $ _________________________________________________________________ 
Total Due $ _______________
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AN ITEMIZED STATEMENT IS NOT NECESSARY UNTIL WE ASK FOR IT
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SEND OUR CHECK TO:   Creditor's No. _________________________ 
Phone # _____________________________
Name _________________________________________________________________________
Address __________________________________________________ Zip _______________
Name of Authorized Representative _______________________ Date _______________