Report Direct Action Payments

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Contact Information

Contact Name^*

CCB Client Number (if known)

Facility Name^*

Email

Payment 1

Debtor's Name^*

Reference #^*

Amount Paid^*

Remaining Balance^*

Any other info we may need about debtor

Payment 2

Debtor's Name

Reference #

Amount Paid

Remaining Balance

Any other info we may need about debtor

Payment 3

Debtor's Name

Reference #

Amount Paid

Remaining Balance

Any other info we may need about debtor

Payment 4

Debtor's Name

Reference #

Amount Paid

Remaining balance

Any other info we may need about debtor

Payment 5

Debtor's Name

Reference #

Amount Paid

Remaining Balance

Any other info we may need about debtor

Payment 6

Debtor's Name

Reference #

Amount Paid

Remaining Balance

Any other info we may need about debtor

Payment 7

Debtor's Name

Reference #

Amount Paid

Remaining Balance

Any other info we may need about debtor

To be the best in our industry,
we have to give the best and produce the best result

- and we do.