Assignment Form

1. Debtor’s Last Name:
2. Middle Name:
3. First Name:
4. Address:
5. Home Phone Number:
6. SSN:
7. Date of Birth:
8. Employer:
9. Work Phone Number:
10. Spouse Name:
11. Spouse SSN:
12. Spouse Date of Birth:
13. Spouse Employer:
14. Spouse Address:
15. Account Number:
16. Date of Last Service:
Payment?

Yes

No
Date of Payment:
18. Principal:
19. Interest:
20. Total:
21. Additional Comments:
22. Your Firm Name:
23. Phone Number:
24. Address:
25. Date:
26. Authorized By:
It is understood that RCA’s commission is earned regardless of whether payment is made directly to RCA or you. No assignment shall be withdrawn while in the process of immediate collection, negotiation, or adjustment without paying full commission. Before an assignment is withdrawn, RCA shall receive thirty (30) days written notification.I understand that failure by client to pay commission due RCA upon billing will result in a delinquency subject to interest, attorney fees and court costs.

Any payment made directly to you should be reported immediately to RCA.

Our regular recovery rates are contingency fees. Any interest added after assignment will be retained by the agency as additional compensation for services rendered. Court costs will be advanced by the agency when legal action is deemed advisable.

We thank you for your business.

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