Claim Form

General Placement Form

Creditor Information

Contact Name

Company Name

Street Address

City

State/Province

Zip

Country

Phone

Fax

E-mail

We hereby place this account with S.S. Sampliner & Co., Inc.

Debtor Contact

Debtor Company Name

Debtor Address

City

State/Province

Zip

Country

Debtor Phone

Debtor Fax

Debtor E-mail

Amount of Claim (please indicate U.S. dollars or foreign currency)

Comments

Enter comments or special instructions here.

(please submit claim form before proceeding to file upload page)


	Submit A Claim
	Please use this form to submit a claim to S.S. Sampliner & Co., Inc. When complete, you may submit your claim directly to our Web site or print the form and fax it to us at: (001) 1-212-239-4898. For further assistance please call us at: (001) 1-212-239-4888
	Upload A File
	You may attach additional supporting documents. Accepted file formats include: Text Word Comma Delimited Excel
	Mail A Claim
	You may print this form and submit your claim by mail to: S.S. Sampliner & Co., Inc. 505 Eighth Avenue New York, NY 10018 Please include any supporting documentation with your claim.

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