Cost Recovery Corp.

Committed to Assisting Municipal Safety Services

CLIENT START SUMMARY

Dept. Name:

Date:

Contact:

Address 1:

Address 2:

City:

State:

Zip:

Phone 1:

Fax 1:

Phone 2:

Fax 2:

Email:

Document Signed
Contract Ordinance Resolution Declaration Other

Product Type
FIRE MVA STRUCTURE FIRE POLICE MVA

Billing Status
Residents Residents' Insurance Non-Residents Non-Residents' Insurance Collection Service

Client Financial Contact

Check Payable To:

Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

TaxID:

Payment Method
Wire Transfer Direct Deposit Check Mailed

:

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