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Please Fill out all of the information completely and accurately to prevent delays.

***Please Note that our fee for funding is 10% of the total amount funded.

First Name *

Last Name *

Phone *

Email *

Address

Street Address *

City *

State *

Country

Postal code *

Date of birth *

Preferred Method Of Communication

Call

Text

Email

How Many Debt Collectors Are Contacting You? *

1

2

3

4+

Please list all of the debt collectors contacting you

Debt Collector
Debt Collector
Debt Collector
Debt Collector
Debt Collector
Debt Collector
Debt Collector
Debt Collector
Debt Collector

Do you think you owe these debt/debts? *

Have you disputed any of these debt/debts?

Have You Made Any Payments to These Debt Collectors In the Past 12 Months

Are you being sued by any of these debt collectors?

If you are being sued how many debt collectors are you being sued by?

1

2

3+

What are the names of the debt collectors suing you?

Have you been served and if so what date were you served?

Please Upload Any Supporting Documents Including any text messages, emails, letters, disputes, credit reports, payments made, or anything else that can help us against the debt collectors.

Do you have any other information you would like us to know?