Influencer Payment Recovery Form
Please fill out the form below to provide the necessary information for us to assist you in recovering the funds owed to you by an agent, brand, or agency.
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Email *
Personal Information 
Name *
Phone number (if I determine I can help you, I will reach out) *
Agency/Brand Information
Name of Agency/Agent/Brand that Owes You Money

 *
Contact Person You Worked With:
 *
Payment Details 
Amount Owed to You: [Amount in USD]
 *
Due Date for Payment: [MM/DD/YYYY]
 *
MM
/
DD
/
YYYY
Efforts Made to Get Paid: [Describe Your Efforts]

 *
Reply from the Agency/Agent: [Describe the Reply]
 *
Additional Information
Physical Address of the Agency/Company:
 *
Country Where the Agency/Company is Located:
 *
Website of the Agency/Company: [Website URL]
 *
Social Media Handles of the Agency/Company: [Social Media Links]
 *
Social Media Activity/Signs of Activity 
Is the Agency/Company Active on Social Media? [Yes/No]
 *
Does it Look Like They Are Running Campaigns? [Yes/No]
 *
Are There Signs That They Are Still Operating? [Yes/No]
 *
Explain if yes *
Service Agreement 
Are You Prepared to Invest in the $250 Initial Fee for the Service? [Yes/No]
 *
Disclaimer:

While I typically am able to recover the funds, it is not guaranteed. For amounts over $10,000, I will invoice a 5% recovery fee on top of the $250 initial fee.

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