Claim Submission Form

Requesting Member

Name

Company Name

Notification Level:

(Frequency of email updates you wish to receive from FMCA)

Intensity Level:

(Level of Collection Aggressiveness)

Debtor Company:

"Required Field - Debtor Name"

Claim Amount:$

"Required Field - Amount: Numerals and Decimals Only"

DBA:

Debtor Contact:

"Required Field - Debtor Contact"

Address Line 1:

"Required Field - Debtor Address"

Contact Title/Position:

Address Line 2:

Telephone#: (XXX-XXX-XXXX)

"Required Field - Phone"

City:

"Required Field - City"

Cell#:

State:

"Required Field - State"

Fax:

Zip:

"Required Field - Zip"

Email:

"This is not a valid email address."

Last Transaction Date (mm/dd/yyyy):

"Required Field - Last Trans Date"

Last Pay Date (mm/dd/yyyy):

Customer No.:

"Required Field - Cust. Number"

State Of Incorporation (If Applicable):

(e.g., NC, TX, NY, DE)

Select One:

Proprietorship Partnership Corporation

Please Answer Yes or No

CLAIM DISPUTED:

DEBTOR HAS FILED BANKRUPTCY:

DEBTOR IS GOB:

PERSONAL GUARANTEE:

ACCOUNT INSURED:

Check All That Apply

SEND TO ATTORNEY UPON RECEIPT WITHOUT FMCA COLLECTOR CONTACT (FREE-DEMAND PERIOD WAIVED)

DO NOT USE ATTORNEY WITHOUT APPROVAL

COMMENTS :

Enter Your Email Address:

"This is not a valid email address."

Additional MEMBER Email Address (cc:):

"This is not a valid email address."

Additional MEMBER Email Address (cc:):

"This is not a valid email address."

Please submit claim documentation as attachment(s) to this form by clicking the "Select files..." button below and navigate to the file on your computer. Once you have selected the file, click "Open" in the file picker to add the file to the attachment list. (If you have multiple files, please repeat this process for each file). You may also email additional supporting claim documentation to CLAIMS@fmcainc.com. Click "Submit" at the bottom of this form when you are ready to send.

NOTICE PLEASE FORWARD STATEMENT OF YOUR ACCOUNT TO FURNITURE MANUFACTURERS CREDIT ASSOCIATION AT YOUR EARLIEST CONVENIENCE. (Please include with this Statement of Account all invoices, credit application, personal guaranty, NSF checks, UCC filings, financial information and any other documentation FMCA may need to provide proof of claim or to use in recourse against the debtor. Uploaded files on this screen will be also be emailed to the debtor if you have entered a valid email address for them) Please notify FMCA of any payments received and refrain from communicating with the debtor as this may hinder the collection process. Please acknowledge receipt of the attached claim and advise our customer that this matter has been referred to you. You, as our agent, are authorized to proceed at once to collect the account on your established rules and rates, to accept payments and to endorse checks, notes, money orders or drafts for deposit, the net proceeds of which you are to remit to us. In the event it becomes necessary to forward this claim to an attorney for legal action, we direct and authorize you, as our agent, and as a convenience to us, to send the account to any attorney only upon prior approval from us. In sending this account to any attorney as our agent,you shall advise the attorney they must obtain from us authorization to file suit, compromise the claim, or grant an extension of time for the payment thereof.

Please enter your initials: (I have read and acknowledge FMCA's collection procedures. ) Required Field - Acknowledgment Initials

* There are required fields above that are still missing details. Please enter the data for those fields.

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