PLEASE ENTER YOUR CONTACT INFORMATION * fields are required. Company Name (*) Company Address (*) Your SNA Client No. (*) Your Full Name (*) Your Phone (*) Your Email (*) ENTER THE DEBTOR'S INFORMATION Debtor Company Name (*) Company Address (*) City (*) State (*) Zip Debtor Primary Phone (*) Debtor Mobile Phone Debtor Email (*) Debtor's Website PLEASE ENTER DETAILS ABOUT OUTSTANDING ACCOUNTS OWED Customer Reference Number Last Sale Date Principal Amount* Client Added Fees Interest Other Amount Total Due* OTHER INFORMATION Where does the debtor bank? Account Number What product or service was sold Last Call Account Executive Contact Operating Unit Please check all that apply: Avoiding Any/All Contact Disputed Failed Payment Commitments Any other details about this account we should know: UPLOAD ADDITIONAL SUPPORTING DOCUMENTS Authorization to proceed: The Client hereby authorizes Swisher & Associates, LLC to proceed at once to collect the above amount. The client agrees to pay Swisher & Associates, LLC to agreed-upon commissions for any and all monies or value received by Swisher & Associates, LLC, the creditor, or the creditors designates in relation to this account, from any source, from the date this agreement is signed. The client hereby agrees to assign Swisher & Associates, LLC an interest in the account, in the amount indicated above. Swisher & Associates, LLC is authorized to negotiate with the debtor to compromise and settle this matter, and to accept payments from the debtor. However, no settlement will be final without approval by the client. If the client determines that litigation is necessary, the account will be referred to the attorney the client designates. All payments on this account made directly to Swisher & Associates, LLC will be reported to the client, and paid over to the client, minus the agreed-upon commission. The Client further expressly appoints Swisher & Associates, LLC as its attorney-in-fact and gives Swisher & Associates, LLC power of attorney to negotiate any checks received by Swisher & Associates, LLC in reference to account assigned by Client. The Client agrees to report all payments made on this account to Swisher & Associates, LLC and to tender the agreed-upon commission immediately upon receipt. All funds collected in a particular month are paid on the 20th of the following month respectively. This schedule enables checks to be cleared and processed for the entire month.