You are not committed until you pay the Tax Invoice we send you.
 
*Compulsory FieldsPrint This Page
Your Email Address: *
 
YOUR INFORMATION
Full name(s) if an individual or company name if a company or name of trustee, if a trust: *
Postal Address: *
Suburb: *
State:  
Postcode: *
Contact Person and position: *
Telephone: *
Leave no spaces (e.g. 98745000)
Mobile:
If you are a corporation your ACN or ABN:
 
DETAILS OF THE PERSON OR COMPANY TO SUE ('DEFENDANT')
Full name of individual or company:*
Contact Person:
Email:
Telephone:
Leave no spaces (e.g. 98745000)
Mobile:
Leave no spaces (e.g. 0400058004)
Defendant is a corporation, its ACN or ABN:
Postal Address: *
Suburb: *
State:  
Postcode: *
 
PARTICULARS OF YOUR CLAIM
Nature of Debt (service or goods or other):*
Amount of Claim: * $
Description of service or goods or other:*
Date of services or sale of goods:*
Is the debt amount disputed?* Yes No
If yes, basis of dispute:
Does the Defendant have any claim against you? Yes No
If yes, full details of claim:
Further relevant information and additional comments:
 
YOUR ACTION TO DATE
Has there been any correspondence with the Defendant?* Yes No
If Yes, summarize:
 
YOUR DOCUMENTS
Please provide copies of the following documents
  1. Contract/Agreement
  2. Credit Application
  3. Invoices/Statements
  4. Correspondence (including emails)
  5. Enrolment Forms
  6. New Customer/Client/Patient Forms
  7. Directors Guarantees
  8. Correspondence between you and the Defendant
 
OTHER INFORMATION
Do you have an Attachment? *
Yes No
To assist with collection, we need a copy of the relevant documents. If unable to attach at this time, proceed to Enforcement Action to be Taken.
Please attach any relevant Information:
Please limit to a file size of maximum 1MB with 4 attachments
 
Date:29/10/2021
Name: *
Typing your name above constitutes your signature
Position: * Principal Director Employee
Your position (tick one box only)
Upon receipt of your completed Action Form, we will email a Tax Invoice to you for the amount detailed in the Mendelsons Fixed Price Fully Inclusive Legal Solutions notes.
 

Please type what you see:

 
You are not committed until you pay the Tax Invoice we send you.