Credit Services Intake Form

Credit Services Intake Form
Do you already have the active MYFREESCORENOW account on our site?*

YesNo
PLEASE CLICK HERE TO RECEIVE YOUR CREDIT MONITORING! THIS IS MANDATORY WE CANT MOVE FORWARD WITHOUT IT!
Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address (If less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email*
example@example.com
Date of Birth

MonthDayYear
Referred By

First NameLast Name
Employed By

First NameLast Name
Government-issued identification card, such as a driver's license or state ID card; please be sure the document is legible.*

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Social Security Card (if you dont have it, a W2/1099 or 1040(tax return) will work)*

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Utility bill with the correct address*

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Reason/Goals for Credit Repair*
Have you and your spouse ever used a credit repair company to dispute any accounts before?

YesNo
Name of Company
When?
Date or year disputed
What accounts were disputed?
Are you planning on making any large purchases on your credit cards even though you will pay it off in a short time?

YesNo
This is an important question because your utilization ratio can increase and reduce scores during our process increasing your credit score. Please write your initial that you understand this.
Date

MonthDayYear
Date
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Credit Services Intake Form
Dear Client,

Thank you for retaining HARMONYPEAK LLC to help improve your credit standing. We understand that the process of working to improve your credit can be confusing and difficult at times. So, in order to ensure that you completely understand the process, please read the following pages carefully. Upon review, complete all enclosed paperwork and return it to us with proper documentation and payment.
Please be sure to send us copies of all correspondence you receive from the Credit Bureaus after you retain us. The information contained in the reports you receive from the Credit Bureaus is essential to proceed in improving your credit rating.

We look forward to helping you to restore your credit to a good standing and feel confident that you are making the right choice by hiring our company.

One-Time Credit Enhancement Package - $399

Scope of Service
By purchasing this service, the Client understands and agrees that the Credit Blast Service includes:

✅ One (1) Round of Aggressive Credit Dispute & Attack – We will submit an aggressive challenge to negative, inaccurate, or questionable items on your credit report with all three major credit bureaus (Experian, Equifax, and TransUnion).

✅ Credit Consultation & Analysis – A one-on-one review of your credit report to identify key issues and potential improvement areas.

✅ Personalized Credit Building Plan – A strategic action plan tailored to help you rebuild and strengthen your credit profile.

✅ 45-Day Process – The credit dispute process typically takes up to 45 days to receive responses from the bureaus.

Important Disclosures
⚠️ No Guaranteed Removals – We do not guarantee the removal, deletion, or correction of any specific item(s) in the first round. Some disputes may require additional rounds, different methods, or escalations.

⚠️ Additional Rounds Available – If additional rounds of dispute are needed beyond the initial Credit Blast, they can be provided for an additional $99 per round.

⚠️ Client Responsibilities – Client must provide accurate personal information and access to their credit reports for the Company to perform the service. Any delays in providing required documentation may impact the dispute timeline.

⚠️ No Refunds – Due to the nature of credit dispute work, there are no refunds once the process has begun.

By signing below, the Client acknowledges they have read, understood, and agreed to the terms of this Credit Blast Service Agreement.
You understand that we do not keep copies of all of the paperwork you forward to us. Due to confidentiality and security reasons, a very limited amount of information is kept in your physical file. All other paperwork is shredded. It is your responsibility to keep copies of any paperwork that you may want to reference at a later date.

YesNo
You understand that you should not send original court documents or collection notices to us. Only send copies of documents that will support your case (i.e. proof of payment, court dismissal documents, etc.). We are not acting as your legal guardian in any way and it is your responsibility to seek outside legal assistance if the need ever arises for an Attorney needed to protect your rights.

YesNo
CREDIT REPAIR ORGANIZATIONS ACT
SEC. 405. DISCLOSURES
(a) Disclosure Required. Any credit repair organization shall provide any consumer with the following written statement before any contract or agreement between the consumer and the credit repair organization is executed:
Consumer Credit File Rights under State and Federal Law
You have a right to dispute inaccurate information in your credit report by contacting the credit bureau directly. However, neither you nor any ''credit repair'' company or credit repair organization has the right to have accurate, current, and verifiable information removed from your credit report. The credit bureau must remove accurate, negative information from your report only if it is over 7 years old. Bankruptcy information can be reported for 10 years.

You have a right to obtain a copy of your credit report from a credit bureau. You may be charged a reasonable fee. There is no fee, however, if you have been turned down for credit, employment, insurance, or a rental dwelling because of information in your credit report within the preceding 60 days. The credit bureau must provide someone to help you interpret the information in your credit file. You are entitled to receive a free copy of your credit report if you are unemployed and intend to apply for employment in the next 60 days, if you are a recipient of public welfare assistance, or if you have reason to believe that there is inaccurate information in your credit report due to fraud.

You have a right to sue a credit repair organization that violates the Credit Repair Organization Act. This law prohibits deceptive practices by credit repair organizations. You have the right to cancel your contract with any credit repair organization for any reason within 3 business days from the date you signed it.

Credit bureaus are required to follow reasonable procedures to ensure that the information they report is accurate. However, mistakes may occur.

You may, on your own, notify a credit bureau in writing that you dispute the accuracy of information in your credit file. The credit bureau must then reinvestigate and modify or remove inaccurate or incomplete information. The credit bureau may not charge any fee for this service. Any pertinent information and copies of all documents you have concerning an error should be given to the credit bureau.

If the credit bureau's reinvestigation does not resolve the dispute to your satisfaction, you may send a brief statement to the credit bureau, to be kept in your file, explaining why you think the record is inaccurate. The credit bureau must include a summary of your statement about disputed information with any report it issues about you. The Federal Trade Commission regulates credit bureaus and credit repair organizations. For more information contact: The Public Reference Branch Federal Trade Commission Washington, D.C. 20580'.
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Privacy Notice
This privacy notice explains our privacy policies and practices, the type of information we collect and how you can direct us not to share certain information with third parties. The practices described in this policy are applicable to current and past clients that do business with HARMONYPEAK LLC. The policy also explains how HARMONYPEAK LLC protects the Confidentiality and security of our client’s information.

1. HARMONYPEAK LLC collects non-public personal information about you from the following sources:

a. Information we receive from your application with HARMONYPEAK LLC.

b. Information we receive from the Credit Bureaus

c. Information we receive from our affiliates or other third parties

2. HARMONYPEAK LLC will not disclose non-public personal information about you without a written authorization.

3. To protect your non-public personal information, we maintain physical and procedural safeguards that comply with federal guidelines.

I have read and received a copy of the Privacy Notice on the date described below.
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Credit Services Intake Form

Credit Services Intake Form

CREDIT REPAIR ORGANIZATIONS ACT

SEC. 405. DISCLOSURES

Consumer Credit File Rights under State and Federal Law

Privacy Notice