Employement Claims — Marylou Paolucci & Associates, P.C.

Employment Agency Claims Form

Temporary Service / Search Firm / Staffing Service Employment Agency / Pay-rolling Agency / Employee Leasing

If you have any questions regarding this form please contact us.

Your Company Information

Full Legal Corporate Name

including any d/b/a (doing business as) or trade names

Company Contact

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Debtor Information

Account Number

Full Name of Debtor Company

Last Known Address On File

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Amount Now Due

excluding interest or finance charges

Any Prior Partial Payments Made

furnish copies of any checks

Additional Information Required Only for Temporary Labor Bills:

Date of Oldest Unpaid Bill

YYYY

Additional Information Required Only for Permanent Placement Fees:

Name of Candidate Placed

First Name

Last Name

Start Date of Employment

YYYY

If Fee is a Percentage of the Starting Salary:

What is the Salary

What is the Fee

Guarantee Period:

Any Guarantee Period

Did Applicant Last Beyond Guarantee?

Nature of Any Dispute

Name of Placement Counselor

Who made fee agreement

First Name

Last Name

Name of Person From Client Who Made Fee Agreement With Counselor

First Name

Last Name

Please furnish any written fee agreement or confirmation and invoice.

Additional Information require Only for Stolen Temps:

Date that the Debtor Hired the Temp Directly

YYYY

Name of Temp

First Name

Last Name

If Fee is Percentage of the Starting Salary:

What is the Salary

Presumed

What is the Fee

Any Additional Information

Marylou Paolucci & Associates, P.C.

16 Trent Lane

Smithtown, New York 11787

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