Debt Enrollment Form

1
We promise to keep this simple. Tell us your name:* This field is required.
First Name
Last Name
2
How do we reach you?By providing your info below, you agree that you have read the privacy policy and consent to us using the information provided to contact me about this inquiry. Standard messaging & data rates may apply, message frequency may vary.
Please enter your email
Please enter your phone
3
We love birthdays. When's yours?* This field is required.
Date
Month
Day
Year
4
Awesome! Now tell us about your loans + how we can help. You can leave these fields blank if you don't have the information on hand. Our team will reach out to your lender for further details.
Lender Name
Your balance $$
Customer Support Email
Loan ID or Account #
Loan 1
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Row 0, Column 1
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Loan 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Loan 3
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Loan 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Loan 1
Loan 2
Loan 3
Loan 4
Lender Name
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Your balance $$
Row 0, Column 1
Customer Support Email
Row 0, Column 2
Loan ID or Account #
Row 0, Column 3
Lender Name
Row 1, Column 0
Your balance $$
Row 1, Column 1
Customer Support Email
Row 1, Column 2
Loan ID or Account #
Row 1, Column 3
Lender Name
Row 2, Column 0
Your balance $$
Row 2, Column 1
Customer Support Email
Row 2, Column 2
Loan ID or Account #
Row 2, Column 3
Lender Name
Row 3, Column 0
Your balance $$
Row 3, Column 1
Customer Support Email
Row 3, Column 2
Loan ID or Account #
Row 3, Column 3
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Tell us about your goal with your loan(s)?
Lower monthly payment
Settle for a lower payoff
Waive/Lower late fees
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ID info* This field is required.We may use this information to verify your identity. FYI: We do not report to credit bureaus. Your score will not be affected by this form.
SSN
What's your address?
7
This document gives us permission to talk to your lender to negotiate on your behalf. SCROLL TO SIGN ↓* This field is required.As either Client or Co-Client, the undersigned individuals whose signatures appear below hereby authorize Flexible Debt USA to act as their agent in speaking with their creditors and negotiating the settlement of any and all claims, suits, liens, judgments, and/or disputes related to the debts listed on the attached List of Creditors associated with the Agreement. The undersigned also authorizes Flexible Debt USA to provide a copy of this authorization to creditors, collection agencies, or others involved with the listed debts, and to confirm the validity of such debts. Flexible Debt USA is allowed to designate employees, agents, or third parties to assist in the negotiation of these settlements. The undersigned grant Flexible Debt USA full power and authority to perform all acts necessary or convenient to complete these tasks, ratifying and confirming all lawful actions taken by Flexible Debt USA on their behalf. If the recipient is a collection agency, they are not permitted to contact the undersigned individuals pursuant to 15 U.S.C. 5 1692C.-The undersigned authorizes all communications regarding debt collection to be directed to Flexible Debt USA from any creditor, collection agent, attorney, credit bureau, or third party.- The recipient of this document is instructed to direct all communications to Flexible Debt USA.- Creditors or their representatives cannot contact the undersigned regarding the claims subject to this authorization without prior written consent.- This authorization allows the recipient to provide Flexible Debt USA with any information they would provide to the undersigned, including but not limited to information about any payable, debt or account.- Flexible Debt USA is authorized to obtain and review personal information necessary to negotiate, inquire, or resolve creditor claims, including consumer credit reports, bank and creditor account information, employment status, and financial information.
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