Debt Collector Intake Form

Debt Collector Intake Form

Please provide details about the debt collectors who are contacting you or appearing on your credit report. Your responses will help us determine if any debt collection laws may have been violated and guide us in assisting you, especially if you'd like the contact to stop.
Section 1: Client Personal Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
State of Residence
Email
example@example.com
1. Debt Collector's Name
2. Debt Collector's Name
3. Debt Collector's Name
4. Debt Collector's Name
5. Debt Collector's Name
Yes, this debt/debts is mineNo, I don't recognize this debt/debts (or the amount is incorrect)I'm not sure
Yes, I have informed them that I disagree or dispute the debt/debtsNo, I have not disputed or disagreed with the debt collectors
Yes, I have sent a letter/email to dispute or request verificationNo, I only told them verballyN/A, I have not disputed
Phone (Calling/Texting)EmailMailCredit ReportSocial Media or other messagingIn-person VisitsN/A, they haven't contacted me
Yes, I have paid/settled this debt/debts alreadyNo, I have not paid it
Section 2: Credit Reporting
Yes, I see it on my credit reportNo, It's not on any reportNot Sure, I haven't checked or don't know
Yes, I believe it's accurateNo, there are errors or wrong informationNot Sure, I haven't checked or don't know
Section 3: Next Steps
Yes, I want them to stop contacting me completelyNo
Yes, I'm interested in getting help to make the collector stop contacting meNo
Please Upload Any Screenshots of Communication with the Debt Collector

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Please Upload Any Screenshots of Communication with the Debt Collector

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Please Upload Any Screenshots of Communication with the Debt Collector

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Please Upload Any Screenshots of Communication with the Debt Collector

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Please Upload Any Screenshots of Communication with the Debt Collector

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I understand an attorney will contact me if violations are foundI acknowledge my commitment to this interactive processIf funds remain after attorney fees, I may be awarded $150 for violations, plus the debt will still be deleted permanently.
Thank you for sharing this information.

Our team will review your responses to assess whether the debt collector's actions may violate any applicable laws, such as the FDCPA, FCRA, or TCPA. If you requested assistance, we’ll follow up with recommended next steps. Please rest assured that all information you’ve provided will remain confidential and used solely to support you in addressing this matter.

If you’re being contacted by additional debt collectors, feel free to submit a separate form for each one.
Should be Empty:

Debt Collector Intake Form

Section 1: Client Personal Information

Section 2: Credit Reporting

Section 3: Next Steps