Medical Account

Application

Applicant Info:

MILTON HOLLOWAY

*** ********** **

HARVEST, AL 35749

SS#

Home

Work

Co-Applicant Info (Optional):

SS#

Signature of Applicant:

Signature of Co-Applicant:

P.O. BOX 560

CHELSEA, AL 35043

PHONE: 205-***-**** / FAX: 205-***-****

Please return this form with your contract.

Town & Country Acceptance Corporation

Licensed & Bonded for over 30 years.

Creditor Info:

Name Approximate Balance Contracted Payment

MEDICAL BILL $ 2,000.00 $ 40.00

Address:

Account Number:

MEDICAL BILL $ 400.00 $ 15.00

Address:

Account Number:

MEDICAL BILL $ 400.00 $ 15.00

Address:

Account Number:

IRS $ 900.00 $ 15.00

Address:

Account Number:

Contact this candidate