AUTHORIZATION TO FAX, EMAIL, AND/OR COMMUNICATE WITH THIRD PARTY

If you wish to download and fax the form, please click here.

To submit electronically, please complete and submit the below form.

Please complete the following information and submit form below.

You may call our office at 574-247-0862 for the Account #.

First Name (required)

Last Name (required)

Email Address (required)

Account # (required)

Client Name / Your Creditor

Last 4 Digits of SSN (required)

Year of Birth (required)

Main Phone Number (required)

Work Phone Number

Mobile/Cellular Phone Number

Alt Phone Number

Fax Number

AUTHORIZATION TO FAX: By authorizing fax communications, you are consenting to receive electronic communications from RECEIVE RECOVERY and/or its agents to the fax number you have provided...

AUTHORIZATION TO EMAIL: By authorizing email communications, you are consenting to receive electronic communications from RECEIVE RECOVERY and/or its agents to the email address you have provided...

AUTHORIZATION TO COMMUNICATE WITH THIRD PARTY(IES): By authorizing RECEIVE RECOVERY to communicate with third party(ies), you are consenting to RECEIVE RECOVERY and/or its agents communicating, obtaining, sharing, releasing, discussing and otherwise providing to and with each other public and non-public personal information with the third party(ies) named below regarding your debt...

GENERAL TERMS AND CONDITIONS: By signing this Authorization, you consent to us, our clients and agents using any and all information...

WITHDRAWING CONSENT: You may withdraw your consent by sending a written request to Receive Revenue Recovery specifying which authorization you are withdrawing...

Signature (required)

Date (required)

THIS IS A COMMUNICATION FROM A DEBT COLLECTOR. THIS IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.

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