Asset Collections, Inc.

6600 SW 92^nd Ave Ste #120 Portland, OR 97223 USA 888-279-8601

This is an attempt to collect a debt and any

information obtained will be used for that purpose.

Payment Summary:

Payment Date:

06/16/25

Payment Amount:

Account Number:

Customer IP:

216.73.216.48

Comments:

Credit Card Information:

Card Type:

Name as on Card:

Card Billing Address:

Card Billing Zipcode:

Card Number:

Card Expiration Date:

MMYY

Card ID (CVV2/CID) Number:
[What is the Card ID?]

Email Address:

Phone Number:

Please provide information below if different from billing information:

First Name:

Last Name:

Address:

Address Line 2:

City:

State:

Zip: