Debt Collection Worksheet

Date: April 23, 2012 Debt Collector Information Name: William Forsythe Entity: Individual Address: 123 Main St., Mill Valley, California Phone, Fax, Email: 415 443-1234, (707) 743-1234, wforsythe@ned.com Creditor Information Name: Rothschild & Sons Entity: S-Corp Address: 60 Arthur St., San Rafael, California Phone, Fax, Email: (415) 456-4436, (415) 880-4887, drothschild@ard.com Debtor Information Name: Alex R. Olsen Entity: Individual Address: 123 Main St., Mill Valley, California Phone, Fax, Email: 415 443-1234, _________________, arolsen@whoo.com Type of Debt: Payment for goods Original Due Date: December 01, 2011 Total Amount Due: $10,000.00 Amount currently Due: $8,700.00 Last Payment Amount: $1,500.00 Last Payment Date: February 01, 2012 Late Charges: a 10% late payment fee will be assessed every 30 days of delinquency Name of Contract: Manufacturing Contract date October 6th, 2011 Supporting Documents: _________________ Can Debtor Make Payment: Yes Additional Information: _________________ -Attorney Information Name: Rob Mackabee Address: 35 Palm Circle Dr., Corte Madera, California Phone, Fax, Email: 4157745543, 4158573455, rmacka@lawyer.com

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