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2.
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3.
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4.
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1. My details
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Company name
Contact person
Mr.
Ms.
Email address
Phone number
Country
\n\t
Afghanistan
\n\t
Aland Islands
\n\t
Albania
\n\t
Algeria
\n\t
American Samoa
\n\t
Andorra
\n\t
Angola
\n\t
Anguilla
\n\t
Antarctica
\n\t
Antigua and Barbuda
\n\t
Argentina
\n\t
Armenia
\n\t
Aruba
\n\t
Ascension
\n\t
Australia
\n\t
Austria
\n\t
Azerbaijan
\n\t
Bahamas
\n\t
Bahrain
\n\t
Bangladesh
\n\t
Barbados
\n\t
Belarus
\n\t
Belgium
\n\t
Belize
\n\t
Benin
\n\t
Bermuda
\n\t
Bhutan
\n\t
Bolivia
\n\t
Bonaire
\n\t
Bosnia and Herzegovina
\n\t
Botswana
\n\t
Bouvet Island
\n\t
Brazil
\n\t
British Indian
\n\t
Brunei Darussalam
\n\t
Bulgaria
\n\t
Burkina Faso
\n\t
Burundi
\n\t
Cambodia
\n\t
Cameroon
\n\t
Canada
\n\t
Cape Verde
\n\t
Cayman Islands
\n\t
Central African Republic
\n\t
Chad
\n\t
Chile
\n\t
China
\n\t
Christmas Island
\n\t
Cocos (Keeling) Islands
\n\t
Colombia
\n\t
Comoros
\n\t
Congo
\n\t
Cook Islands
\n\t
Costa Rica
\n\t
Cote d'Ivoire
\n\t
Croatia
\n\t
Cuba
\n\t
Curaçao
\n\t
Cyprus
\n\t
Czech Republic
\n\t
Denmark
\n\t
Djibouti
\n\t
Dominica
\n\t
Dominican Republic
\n\t
Ecuador
\n\t
Egypt
\n\t
El Salvador
\n\t
Equatorial Guinea
\n\t
Eritrea
\n\t
Estonia
\n\t
Ethiopia
\n\t
Falkland Islands
\n\t
Faroe Islands
\n\t
Fiji
\n\t
Finland
\n\t
France
\n\t
French Guiana
\n\t
French Polynesia
\n\t
French Southern Territories
\n\t
Gabon
\n\t
Gambia
\n\t
Georgia
\n\t
Germany
\n\t
Ghana
\n\t
Gibraltar
\n\t
Greece
\n\t
Greenland
\n\t
Grenada
\n\t
Grenadines
\n\t
Guadeloupe
\n\t
Guam
\n\t
Guatemala
\n\t
Guernsey
\n\t
Guinea
\n\t
Guinea-Bissau
\n\t
Guyana
\n\t
Haiti
\n\t
Heard Island
\n\t
Honduras
\n\t
Hong Kong
\n\t
Hungary
\n\t
Iceland
\n\t
India
\n\t
Indonesia
\n\t
Iran
\n\t
Iraq
\n\t
Ireland
\n\t
Isle of Man
\n\t
Israel
\n\t
Italy
\n\t
Jamaica
\n\t
Japan
\n\t
Jersey
\n\t
Jordan
\n\t
Kazakhstan
\n\t
Kenya
\n\t
Kiribati
\n\t
Kuwait
\n\t
Kyrgyzstan
\n\t
Lao
\n\t
Latvia
\n\t
Lebanon
\n\t
Lesotho
\n\t
Liberia
\n\t
Libya
\n\t
Liechtenstein
\n\t
Lithuania
\n\t
Luxembourg
\n\t
Macao
\n\t
Macedonia
\n\t
Madagascar
\n\t
Malawi
\n\t
Malaysia
\n\t
Maldives
\n\t
Mali
\n\t
Malta
\n\t
Marshall Islands
\n\t
Martinique
\n\t
Mauritania
\n\t
Mauritius
\n\t
Mayotte
\n\t
McDonald Islands
\n\t
Mexico
\n\t
Micronesia
\n\t
Minor Outlying Islands
\n\t
Moldova
\n\t
Monaco
\n\t
Mongolia
\n\t
Montenegro
\n\t
Montserrat
\n\t
Morocco
\n\t
Mozambique
\n\t
Myanmar
\n\t
Namibia
\n\t
Nauru
\n\t
Nepal
\n\t
Netherlands
\n\t
New Caledonia
\n\t
New Zealand
\n\t
Nicaragua
\n\t
Niger
\n\t
Nigeria
\n\t
Niue
\n\t
Norfolk Island
\n\t
North Korea
\n\t
Northern Mariana Islands
\n\t
Norway
\n\t
Oman
\n\t
Palau
\n\t
Palestinian
\n\t
Palestinian Territory
\n\t
Panama
\n\t
Papua New Guinea
\n\t
Paraguay
\n\t
Peru
\n\t
Philippines
\n\t
Pitcairn
\n\t
Poland
\n\t
Portugal
\n\t
Puerto Rico
\n\t
Qatar
\n\t
Romania
\n\t
Russian Federation
\n\t
Rwanda
\n\t
Réunion
\n\t
Saba
\n\t
Saint Barthelemy
\n\t
Saint Helena
\n\t
Saint Kitts and Nevis
\n\t
Saint Lucia
\n\t
Saint Martin
\n\t
Saint Pierre, Miquelon
\n\t
Saint Vincent
\n\t
Samoa
\n\t
San Marino
\n\t
Sao Tome and Principe
\n\t
Saudi Arabia
\n\t
Senegal
\n\t
Serbia
\n\t
Seychelles
\n\t
Sierra Leone
\n\t
Singapore
\n\t
Sint Eustatius
\n\t
Sint Maarten
\n\t
Slovakia
\n\t
Slovenia
\n\t
Solomon Islands
\n\t
Somalia
\n\t
South Africa
\n\t
South Georgia
\n\t
South Korea
\n\t
South Sandwich Islands
\n\t
South Sudan
\n\t
Spain
\n\t
Sri Lanka
\n\t
Sudan
\n\t
Suriname
\n\t
Svalbard and Jan Mayen
\n\t
Swaziland
\n\t
Sweden
\n\t
Switzerland
\n\t
Syrian Arab Republic
\n\t
Taiwan
\n\t
Tajikistan
\n\t
Tanzania
\n\t
Thailand
\n\t
Timor-Leste
\n\t
Togo
\n\t
Tokelau
\n\t
Tonga
\n\t
Trinidad and Tobago
\n\t
Tristan da Cunha
\n\t
Tunisia
\n\t
Turkey
\n\t
Turkmenistan
\n\t
Turks and Caicos Islands
\n\t
Tuvalu
\n\t
Uganda
\n\t
Ukraine
\n\t
United Arab Emirates
\n\t
United Kingdom
\n\t
United States of America
\n\t
Uruguay
\n\t
Uzbekistan
\n\t
Vanuatu
\n\t
Vatican City State
\n\t
Venezuela
\n\t
Viet Nam
\n\t
Virgin Islands, British
\n\t
Virgin Islands, U.S.
\n\t
Wallis and Futuna
\n\t
Western Sahara
\n\t
Yemen
\n\t
Zambia
\n\t
Zimbabwe
Address
Zipcode
City
2. Debtor
* = Required
Company name
Contact person
Mr.
Ms.
Email address
Phone number
Country
\n\t
Afghanistan
\n\t
Aland Islands
\n\t
Albania
\n\t
Algeria
\n\t
American Samoa
\n\t
Andorra
\n\t
Angola
\n\t
Anguilla
\n\t
Antarctica
\n\t
Antigua and Barbuda
\n\t
Argentina
\n\t
Armenia
\n\t
Aruba
\n\t
Ascension
\n\t
Australia
\n\t
Austria
\n\t
Azerbaijan
\n\t
Bahamas
\n\t
Bahrain
\n\t
Bangladesh
\n\t
Barbados
\n\t
Belarus
\n\t
Belgium
\n\t
Belize
\n\t
Benin
\n\t
Bermuda
\n\t
Bhutan
\n\t
Bolivia
\n\t
Bonaire
\n\t
Bosnia and Herzegovina
\n\t
Botswana
\n\t
Bouvet Island
\n\t
Brazil
\n\t
British Indian
\n\t
Brunei Darussalam
\n\t
Bulgaria
\n\t
Burkina Faso
\n\t
Burundi
\n\t
Cambodia
\n\t
Cameroon
\n\t
Canada
\n\t
Cape Verde
\n\t
Cayman Islands
\n\t
Central African Republic
\n\t
Chad
\n\t
Chile
\n\t
China
\n\t
Christmas Island
\n\t
Cocos (Keeling) Islands
\n\t
Colombia
\n\t
Comoros
\n\t
Congo
\n\t
Cook Islands
\n\t
Costa Rica
\n\t
Cote d'Ivoire
\n\t
Croatia
\n\t
Cuba
\n\t
Curaçao
\n\t
Cyprus
\n\t
Czech Republic
\n\t
Denmark
\n\t
Djibouti
\n\t
Dominica
\n\t
Dominican Republic
\n\t
Ecuador
\n\t
Egypt
\n\t
El Salvador
\n\t
Equatorial Guinea
\n\t
Eritrea
\n\t
Estonia
\n\t
Ethiopia
\n\t
Falkland Islands
\n\t
Faroe Islands
\n\t
Fiji
\n\t
Finland
\n\t
France
\n\t
French Guiana
\n\t
French Polynesia
\n\t
French Southern Territories
\n\t
Gabon
\n\t
Gambia
\n\t
Georgia
\n\t
Germany
\n\t
Ghana
\n\t
Gibraltar
\n\t
Greece
\n\t
Greenland
\n\t
Grenada
\n\t
Grenadines
\n\t
Guadeloupe
\n\t
Guam
\n\t
Guatemala
\n\t
Guernsey
\n\t
Guinea
\n\t
Guinea-Bissau
\n\t
Guyana
\n\t
Haiti
\n\t
Heard Island
\n\t
Honduras
\n\t
Hong Kong
\n\t
Hungary
\n\t
Iceland
\n\t
India
\n\t
Indonesia
\n\t
Iran
\n\t
Iraq
\n\t
Ireland
\n\t
Isle of Man
\n\t
Israel
\n\t
Italy
\n\t
Jamaica
\n\t
Japan
\n\t
Jersey
\n\t
Jordan
\n\t
Kazakhstan
\n\t
Kenya
\n\t
Kiribati
\n\t
Kuwait
\n\t
Kyrgyzstan
\n\t
Lao
\n\t
Latvia
\n\t
Lebanon
\n\t
Lesotho
\n\t
Liberia
\n\t
Libya
\n\t
Liechtenstein
\n\t
Lithuania
\n\t
Luxembourg
\n\t
Macao
\n\t
Macedonia
\n\t
Madagascar
\n\t
Malawi
\n\t
Malaysia
\n\t
Maldives
\n\t
Mali
\n\t
Malta
\n\t
Marshall Islands
\n\t
Martinique
\n\t
Mauritania
\n\t
Mauritius
\n\t
Mayotte
\n\t
McDonald Islands
\n\t
Mexico
\n\t
Micronesia
\n\t
Minor Outlying Islands
\n\t
Moldova
\n\t
Monaco
\n\t
Mongolia
\n\t
Montenegro
\n\t
Montserrat
\n\t
Morocco
\n\t
Mozambique
\n\t
Myanmar
\n\t
Namibia
\n\t
Nauru
\n\t
Nepal
\n\t
Netherlands
\n\t
New Caledonia
\n\t
New Zealand
\n\t
Nicaragua
\n\t
Niger
\n\t
Nigeria
\n\t
Niue
\n\t
Norfolk Island
\n\t
North Korea
\n\t
Northern Mariana Islands
\n\t
Norway
\n\t
Oman
\n\t
Palau
\n\t
Palestinian
\n\t
Palestinian Territory
\n\t
Panama
\n\t
Papua New Guinea
\n\t
Paraguay
\n\t
Peru
\n\t
Philippines
\n\t
Pitcairn
\n\t
Poland
\n\t
Portugal
\n\t
Puerto Rico
\n\t
Qatar
\n\t
Romania
\n\t
Russian Federation
\n\t
Rwanda
\n\t
Réunion
\n\t
Saba
\n\t
Saint Barthelemy
\n\t
Saint Helena
\n\t
Saint Kitts and Nevis
\n\t
Saint Lucia
\n\t
Saint Martin
\n\t
Saint Pierre, Miquelon
\n\t
Saint Vincent
\n\t
Samoa
\n\t
San Marino
\n\t
Sao Tome and Principe
\n\t
Saudi Arabia
\n\t
Senegal
\n\t
Serbia
\n\t
Seychelles
\n\t
Sierra Leone
\n\t
Singapore
\n\t
Sint Eustatius
\n\t
Sint Maarten
\n\t
Slovakia
\n\t
Slovenia
\n\t
Solomon Islands
\n\t
Somalia
\n\t
South Africa
\n\t
South Georgia
\n\t
South Korea
\n\t
South Sandwich Islands
\n\t
South Sudan
\n\t
Spain
\n\t
Sri Lanka
\n\t
Sudan
\n\t
Suriname
\n\t
Svalbard and Jan Mayen
\n\t
Swaziland
\n\t
Sweden
\n\t
Switzerland
\n\t
Syrian Arab Republic
\n\t
Taiwan
\n\t
Tajikistan
\n\t
Tanzania
\n\t
Thailand
\n\t
Timor-Leste
\n\t
Togo
\n\t
Tokelau
\n\t
Tonga
\n\t
Trinidad and Tobago
\n\t
Tristan da Cunha
\n\t
Tunisia
\n\t
Turkey
\n\t
Turkmenistan
\n\t
Turks and Caicos Islands
\n\t
Tuvalu
\n\t
Uganda
\n\t
Ukraine
\n\t
United Arab Emirates
\n\t
United Kingdom
\n\t
United States of America
\n\t
Uruguay
\n\t
Uzbekistan
\n\t
Vanuatu
\n\t
Vatican City State
\n\t
Venezuela
\n\t
Viet Nam
\n\t
Virgin Islands, British
\n\t
Virgin Islands, U.S.
\n\t
Wallis and Futuna
\n\t
Western Sahara
\n\t
Yemen
\n\t
Zambia
\n\t
Zimbabwe
Address
Zipcode
City
3. The claim
Amount
EUR
GBP
USD
ANG
AUD
AWG
BAM
BGN
BRL
CAD
CHF
CNY
CZK
DKK
HKD
HRK
HUF
IDR
ILS
INR
JPY
KRW
LTL
MXN
MYR
NOK
NZD
PHP
PLN
RON
RUB
SEK
SGD
THB
TRY
ZAR
Other
On which account can we deposit the collected amount?
Has the claim already been assigned to a debt recovery agent?
No
Yes
Does your customer have a reason not to pay (disputed claim)?
No
Yes
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