Debt Settlement Form

First name

Last name

Email

Mobile phone number

Spouse, First name

Spouse, Last name

Spouse, Email

Spouse, Mobile phone number

How much unsecured debt are you in? (excluding liens and student loans)

Do you have any judgments against you?
NoYes

If so, how much?

Do you currently have the means/ability to pay these alleged delinquent accounts off/if you approve a mutually agreed low settlement amount, in a one-time lump sum payment to the creditor or collector?
YesNo

Do you have the full account numbers for these accounts, or only the partial numbers on a credit report?
Full account numbersOnly partial numbers