Name:

Email:

Your Address:
Adress Line 1:

Suburb:

State:

Postcode:

Name of your Business:

Australian Business Number:

Business Address:
Adress Line 1:

Suburb:

State:

Postcode:

Name of the contact person in your business:

Your telephone number:

Is this a debt owed to your business?
Yes
No

How much is owed?

What day did the debt arise?

What is the debt owed for?
Goods sold
Services provided
Money lent
Strata Levies
Other

Invoice Date

Invoice Number

Due Date

Have you followed up the Debtor for payment?
Yes
No

Have you received any payments toward the invoice? If so, please provide dates and amounts:

Payment Terms

How was the invoice issued?

Was there a purchase order?
Yes
No

Was there a product or service agreement? If so, please provide the date of the agreement:

What services were provided or Goods Sold?

What date were the Services Provided/Goods Sold/Money Lent/Strata Levies?

What date were you instructed to Provide the above Services?

Are there any issues in dispute about the invoice?

Name:

Email:

Address:
Adress Line 1:

Suburb:

State:

Postcode:

Your telephone number:

Contact Person:

Is the Debtor a Company or an Individual?
Company
Individual/s

Business Name

The Director's Name/s

Australian Business Number:

Australian Company Number:

ASIC Registered Office

Principal Place of Business

Who are the Share Holders?