Information About You  (Our Subscriber)                                             

Creditor     Contact            Date

Your Address    City, State Zip   Phone

Your Email   

Information About Your Debtor

Last,First M  Spouse    Check if Spouse is Liable?

Address             City,State Zip    Phone

Subject   Soc Sec#    Date of Birth    Employer    Cell Ph#

Spouse    Soc Sec#    Date of Birth    Employer    Cell Ph#

Information About The Debt

$ owed    mm/dd/yyyy     mm/dd/yyyyy    mm/dd/yyyy  

Current Balance                              Last Purchase                            Last Payment                             Last Delinquency

Do you have a: Note   Contract  Judgment  -  Is Account Disputed?

Notes

Before you submit this claim, please check to be certain that you have complied with all applicable law when assessing collection fees, late fees, periodic interest, etc. Creditor takes full responsibility for any adverse consequences that may result from adding such fees when not permitted by law.