Direct Assignment Form-021216 - Transworld …

1 Direct Collection -2002320 2/16 Page 1 TSI REPRESENTATIVE SALES NUMBER PRINT OR TYPE ONLY DEBTOR NUMBER IIIREFERENCE PAT IENT NAME IDA IMR DEBTOR LAST (OR BUSINESS) NAME FIRST NAME SPOUSE HOME PHONE ( ) IS MAIL RETURNED? YES -NO - PERCENTAGE COMMISSION RATE 50% LAST ADDRESS CITY STATE ZIP CODE DATE LAST CHARGE I IDATE LAST PAYMENT IILAST KNOWN EMPLOYER ADDRESS CITY STATE ZIP CODE PHONE NUMBER ( ) PRINCIPAL INTEREST SPOUSE LAST KNOWN EMPLOYER ADDRESS CITY STATE ZIP CODE PHONE NUMBER ( ) AMOUNT NOW DUE DEBTOR SSN SPOUSE SSN NEAREST RELATIVE PHONE NUMBER ( ) DEBTOR NUMBER IIIREFERENCE NAME IDA IMR DEBTOR LAST (OR BUSINESS) NAME FIRST NAME SPOUSE HOME PHONE ( ) IS MAIL RETURNED' YES -NO - PERCENTAGE COMMISSION RATE 50% LAST ADDRESS CITY STATE ZIP CODE DATE LAST CHARGE I IDATE LAST PAYMENT IILAST KNOWN EMPLOYER ADDRESS CITY STATE ZIP CODE PHONE NUMBER ( ) PRI NCIPAL INTEREST SPOUSE LAST KNOWN EMPLOYER ADDRESS CITY STATE ZIP CODE PHONE NUMBER ( )

2 AMOUNT NOW DUE DEBTOR SSN SPO USE SSN NEAREST RELATIVE PHONE NUMBER ( ) DEBTOR NUMBER IIIREFERENCE NAME IDA IMR DEBTOR LAST (OR BUSINESS) NAME FIRST NAME SPOUSE HOME PHONE ( ) IS MAIL RETURNED? YES -NO - PERCENTAGE COMMISSION RATE 50% LAST ADDRESS CITY STATE ZIP CODE DATE LAST CHARGE I IDATE LAST PAYMENT IILAST KNOWN EMPLOYER ADDRESS CITY STATE ZIP CODE PHONE NUMBER ( ) PRINCIPAL INTEREST SPOUSE LAST KNOWN EMPLOYER ADDRESS CITY STATE ZIP CODE PHONE NUMBER ( ) AMOUNT NOW DUE DEBTOR SSN SPOUSE SSN NEAREST RELATIVE PHONE NUMBER ( ) This form must be signed in order to process the above accounts. SIGNATURE Copyright 2010 - Revised 2/16 - Transworld Systems Inc. - All rights reserved PRINT NAME TITLE TODAY'S DATE YOUR BUSINESS NAME TSI CLIENT # STREET ADDRESS CITY STATE ZIP AREA CODE( ) PHONE NUMBER E-MAIL ADDRESS MAILING ADDRESS Transworld Systems Inc.

3 Attn: Client Services PO Box 17221 Wilmington, DE 19850 Fax: 877-285-8309 IMPORTANT: Do not assign accounts with balances less than $ , bankruptcies, or accounts over 18 months past due. If possible, please fill out ALL information requested on this form . INITIALDIRECT COLLECTION Assignment form INITIALINITIAL The undersigned hereby assign to Transworld Systems Inc., the claims listed above for the purpose of collection at the commission rate of 50% or as otherwise stipulated, and authorizes them to endorse negotiable instruments received in payment of claims, and to deduct commissions on claims paid Direct to me from any money due me. TSI will retain interest and legal fees collected. In consideration for such, TSI will retain all interest calculated on assigned accounts. I agree to report promptly all payments made directly to me after the date of Assignment and further agree that Transworld Systems Inc.

4 Is entitled to full commission due on all monies recovered, whether paid to Transworld Systems Inc. or me Direct after date of Assignment . In case suit or action is instituted to collect such commissions on any of these assignments, the undersigned promises to pay all collection costs and such additional sums as the court may adjudge reasonable such as court costs, attorney fees, etc. Transworld SYSTEMS INC. IS AUTHORIZED TO SUE, SETTLE OR ADJUST ANY CLAIMS AS MAY BE NECESSARY. X