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:13/11/2018
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.
 
You are not committed until you pay the Tax Invoice we send you.