Business Debt Recovery Authority To Act

Please fill out the form below to submit a debt for recovery.

If you have any problems with this form, you may alternatively use the PDF version of the form downloadable here. Please email the completed form and any other relevant information to info@henleyrecoveriesgroup.com.au

Submit Debt & ATA [pre-fill]

Your Details (party who is owed the money)

Also to be referred to as 'the client' in our Authority to Act form below.

Your Business Name

(If you are not a business, please leave this field blank.)

ABN/ACN *

(Please type N/A if you are not a business)

Contact Person Name *

Telephone *

Email *

Debt Details

Amount Owing *

Due Date of Payment *

Other Fees to Charge to Debtor

Debt Recovery Fees (Signed Evidence Required)

Legal Fees (Signed Evidence Required)

Interest (Signed Evidence Required)

Late/Admin Fees (Signed Evidence Required)

Please Provide a Brief Description of the Debt

Please upload any evidence & supporting documents such as invoices here. Any extra fees added must have the signed agreement uploaded.

Maximum file size: 314.57MB

(Evidence could include invoices, correspondence and/or images etc.)

Debtor Details (party who owes the money)

Debtor Business Name

(If the debtor is not a business, please leave this blank.)

Debtor ABN/ACN

Debtor Contact Name *

Debtor's Phone Number

(If you don't have this information, leave blank)

Debtor's Email Address

(If you don't have this information, leave blank)

Debtor's Address

Other Debtor Information

For a easy-read copy of our terms below, please click here.

Authority to Act - Agreement

This is an agreement to appoint a commercial agent. This document is pursuant to section 23 of the Debt Collectors (Field Agents and Collection Agents) regulation 2014.

The Client Hereby: *

Confirms that the person who is named below and has their signature on this form is the nominee signing on behalf of their organisation and has the appropriate level of authorisation to represent their party in this manner

Acknowledges and understands the full terms and conditions of this agreement, as outlined in this form

Agrees that it has been afforded the opportunity to obtain the relevant independent professional advice and/or representation before entering into this agreement

Name of Person Signing *

Position

(if signing on behalf of a business)

Signature *

Clear

Date of Submission *

How Did You Find Out About Us? *

If you are human, leave this field blank.

0466 243 114