About You / Your Debtor Company Name: Contact Name: Phone Number: Email: Has legal action taking place? Yes No If Yes, Please state below what legal action you have taken: Company Address: Debtor's Company / Trading Name: Debtor's Contact Name: Job Role / Title: Number: Email: Their Address: Website: Issue Date of Unpaid Invoice: Your Invoice Ref: Please include Invoices, Proof of receievd services, emails associated etc. Outstanding Invoice amount (including VAT if relevant): Interest including VAT (include VAT if your T&Cs allow): Admin/Collection Costs including VAT (see notes below): Total to be Collected (including VAT if relevant): Please Note: Any interest will be crystallised upon receipt. For Non-Consumer Credit Act Cases, if your T&Cs allow, interest can be added in the space above. A 10% commission of the total money our agents collect on your behalf will become payable to us once it arrives in your bank account. If an amount is not entered, we will assume you do not wish to add these costs: I Understand What is the reason for the debt? For example, unpaid invoice: Does your debtor have vulnerabilities or special needs that you are aware of?: Yes No If Yes, Please provide a brief summary here: If your debtor cannot pay in full on the day, what is an acceptable minimum monthly payment?: Authorisation To Act On Your Behalf: I hereby authorise Diary Of A Debt Collector Limited and their agents to act for me/us in the collection of the debt and costs as listed above in your Instruction Form. This includes the recovery on a face-to-face basis and such legal proceedings as may be required. By signing this document, I also confirm that I have read, understood and accept your terms and conditions. Send © Stratton Debt Associates Limited2026
