Fax Form

MERCHANTS FINANCIAL GUARDIAN, INC.
A PROFESSIONAL COLLECTION CORPORATION
(VIA FAX)

COMPLETE AND MAIL OR FAX BOTH PAGES TO: (keep a copy for your records)

MERCHANTS FINANCIAL GUARDIAN, INC.
1215 W. IMPERIAL HIGHWAY, #208
P.O. BOX 248
BREA, CA 92822-0248
PHONE: (714) 680-8345 FAX: (714) 870-0352

(please check one)
[ ] IMMEDIATE CLAIM PLACEMENT
[ ] 10 DAY FREE DEMAND

PLEASE PROCEED WITH IMMEDIATE COLLECTION ON THE ACCOUNT LISTED. WE AGREE TO NOTIFY YOU
PROMPTLY OF ANY PAYMENTS RECEIVED. WE HAVE READ AND AGREE TO ABIDE BY THE TERMS &
CONDITIONS ON PAGE 2 OF THIS ASSIGNMENT FORM.

DEBTOR..............................................................................................................................................................................................

ADDRESS...........................................................................................................................................................................................

CITY........................................................................................................................STATE/ZIP.......................................................

NAME OF CONTACT ....................................................................................................................................................................

TELEPHONE (........).............................................................................................CUSTOMER.......................................................

BALANCE DUE $................................................................................DATE OF LAST CHARGE..............................................

DEBTOR ENTITY: _______CORPORATION _______PARTNERSHIP _______INDIVIDUAL _______LLC

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PLEASE ENCLOSE THE FOLLOWING:

_____INVOICES _____ITEMIZED STATEMENT _____CREDIT APPLICATION _____OTHER DOCUMENTS

COMMENTS/SUGGESTIONS......................................................................................................................................................

...........................................................................................................................................................................................................

WE APPRECIATE ANY COMMENTS YOU FEEL WOULD BE OF VALUE TO EXPEDITE THE RECOVERY OF
THIS CLAIM.

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MERCHANTS FINANCIAL GUARDIAN, INC. IS AUTHORIZED TO FORWARD THIS CLAIM TO AN ATTORNEY
IF NECESSARY. NO LEGAL ACTION WILL BE TAKEN WITHOUT OUR PRIOR WRITTEN APPROVAL.

CREDITOR.....................................................................................................................................................................................

ADDRESS.......................................................................................................TELEPHONE (.......).............................................

CITY...............................................................................................................STATE/ZIP............................................................

SIGNATURE..................................................................................................FAX (........)............................................................

PRINT NAME...............................................................................................................................................................................

MERCHANTS FINANCIAL GUARDIAN, INC.
A PROFESSIONAL COLLECTION CORPORATION

TERMS & CONDITIONS

MERCHANTS FINANCIAL GUARDIAN, INC. (hereinafter referred to as "MFG") and the CREDITOR (hereinafter referred to as "Client") agree and intend to be bound by the following terms and conditions:

Client agrees that, once the claim has been assigned to MFG, no other agency, person nor the client shall concurrently pursue this claim. Should payment be made, MFG shall be entitled to collection fees as outlined in paragraph 6.

Client agrees that, as the agent for client, MFG is authorized to accept payments and endorse for deposit checks or money orders received on accounts, the net proceeds of which MFG shall remit to client in a timely fashion. MFG shall deposit all such funds into a clients’ trust account.

Client agrees that, if MFG is entitled to fees as a result of payments made directly to client, MFG may deduct those fees from subsequently received payments on the same claim or on other claims.

Accounts withdrawn or settled directly by the client are nevertheless subject to collection fees, as outlined in paragraph 6.

MFG shall be entitled to a service charge of no less than 50% of the collection fee stated in paragraph 6, when a) returned merchandise accepted by the client is considered direct settlement or b) client refers a claim to MFG, which is subsequently demonstrated to have been paid by the debtor prior to the referral to MFG.

Commercial Collection Rates: Charges contingent upon collection are 25% on the first $2,000 collected and 20% in excess of $2,000. All balances assigned under $300 are 50%. Second placements are all accounts previously handled by other agencies or attorneys. The collection fee on these accounts is 50%. Legal action shall not be taken without client’s written authorization, once suit is filed, a 10% increase in fee will apply. If suit is recommended, there may be additional expenses for court costs and attorney retainer. Interest collected is retained by MFG as additional compensation. Additionally, treble damage charges on non-sufficient fund checks assigned for collection shall be shared with client at the prevailing commission rate.

Accounts assigned for collection may be listed on Experian credit bureau at the sole discretion of MFG.

NO COLLECTION NO FEE