Debt Collector Intake Form
Please provide details about the debt collector who is contacting you or appearing on your credit report. Your responses will help us determine if the debt collector may have violated any debt collection laws and guide us in assisting you, if you'd like the contact to stop.
Section 1: Personal Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section 2: Debt Collector Details
Debt Collector’s Name
*
Who is contacting you about the debt?
Original Creditor
If different, who is the original company you owed?
Approximate Debt Amount
About how do they say you owe?
Date of Last Payment to Original Creditor?
-
Month
-
Day
Year
Date
Do you think you owe this debt?
*
Yes – I recognize this debt as mine.
No – I don’t owe this debt (or the amount is incorrect).
I am not sure
Have you already paid this debt (partially or in full)
*
Yes – I have paid/settled this debt already.
No – I have not paid it.
If you have already paid this debt, what date was it paid?
-
Month
-
Day
Year
Date
How did you first learn about or hear from this debt collector?
*
They contacted me by phone call or text.
I received a letter or email from them.
I saw this debt on my credit report.
I was served with court papers about this debt.
Other/Not sure
Have you ever told the debt collector that you dispute the debt ?
*
Yes – I informed them I dispute or disagree with the debt.
No – I have not disputed the debt with them.
If you disputed the debt, did you do so in writing? (e.g. sending a letter or email to the debt collector)
*
Yes – I sent a letter/email to dispute or request verification.
No – I only told them verbally.
N/A, I have not disputed this debt.
If you disputed this debt, when did you dispute?
-
Month
-
Day
Year
Date
After you disputed the debt, did the debt collector provide proof of the debt or stop contacting you about it?
*
Yes – They provided verification/proof or stopped contacting me.
No – They kept contacting me without proving the debt.
N/A, I have not disputed this debt.
Section 3: Communication and Contact Methods
Contact Methods: How does this debt collector typically contact you? (check all that apply).
*
Phone calls (speaking with a live person)
Voicemail messages
Text messages
Emails
Letters by mail
Social media or other messaging
N/A, they do not contact me
Did they send a written notice about the debt after first contacting you? (Debt collectors must send a written notice with details of the debt and your rights within 5 days of the first contact.)
*
Yes – I received a letter with information about the debt (within a week of first contact)
No – I never received any written notice
Have they ever contacted you before 8:00 AM or after 9:00 PM, your local time? (Debt collectors generally should not contact you outside 8:00 AM to 9:00 PM)
*
Yes – They contacted me early in the morning or late at night.
No – They only contact between 8am and 9pm.
If the debt collector contacted you before 8:00 AM or after 9:00 PM, please provide the dates below.
Example: 01/31/2025 at 7:00 AM
Contact at Work: Has the debt collector ever contacted you at your workplace or called you on a work number?
*
Yes – They contacted me at work.
No – They have not contacted me at work.
Contacting Others: Debt collectors are not allowed to discuss your debt with anyone but you (or your spouse). To your knowledge, has the debt collector ever contacted any other individual about your debt (e.g. your family, friends, or neighbors)?
*
Yes – They contacted someone else about my debt.
No – They have not contacted others.
Not sure
Have you asked the debt collector to stop contacting you or to only contact you in a certain way? (e.g. telling them “stop calling me” or asking for only written contact.)
*
Yes – I have requested they stop or limit contact.
No – I have not made any specific request.
If you asked the debt collector to stop contacting you, when did you make the request?
-
Month
-
Day
Year
Date
If yes, did they stop contacting you after your request? (By law, after a written stop request has been sent, the debt collector should only contact you to confirm receipt of the request or to advise they will be taking further legal action).
*
Yes – They honored my request and stopped contacting me (or only followed specified contact request).
No – They ignored my request and have continued contacting me.
N/A
Section 4: Debt Collector’s Behavior and Conduct
Check any of the following behaviors you have experienced from this debt collector: (check all that apply)
*
They use obscene, vulgar, or profane language when speaking with me.
They call very frequently or repeatedly to annoy/harass me (e.g. calling numerous times a day or over 7 times in one week).
They have threatened me with harm, violence, or other personal harm.
They have threatened serious actions against me, such as arrest, lawsuits, wage garnishment or seizing property (and I believe they either cannot or do not actually intend to do these).
They did not properly identify themselves as a debt collector when contacting me (e.g. they tried to hide that they are collecting a debt).
N/A
Section 5: Credit Reporting
Is this debt showing on your credit report? (e.g. Experian, Equifax, or TransUnion report).
*
Yes – I see it on my credit report.
No – It is not on any of my credit report(s).
Not sure – I haven’t checked my credit report(s) or don’t know.
If yes, is the information about the debt on your credit report accurate (correct amount, status, dates, etc.)?
*
Yes – It appears accurate.
No – There are errors or wrong information.
Not sure – I haven’t checked or don’t know.
Have you disputed this debt through the credit bureau(s)?
*
Yes – I disputed it with the credit bureau.
No – I have never disputed this account.
Not sure/not applicable.
Section 6: Next Steps
Do you want this debt collector to stop contacting you?
*
Yes – I want them to stop contacting me completely.
No
Would you like help with this?
*
Yes – I’m interested in getting help to make the debt collector stop contacting me.
No
Please add any additional information regarding this debt collector.
Please upload any screenshots of communication with the debt collector.
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Please upload a copy of your credit reports, if available.
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Check each box below that you agree and understand:
*
I voluntarily agree to participate in the intake and debt violation review process conducted by Jackie J Consulting. I understand that the purpose of this intake form is to evaluate potential violations of consumer protection laws by debt collectors.
I agree to remain responsive and available throughout the process. If I fail to respond to communications or request for information within 72 hours, I understand I may be removed from the program without further notice.
I understand that no one from Jackie J Consulting has made any promises or guarantees regarding the deletion of items from my consumer report, the outcome of any legal demand or settlement or financial relief of any kind.
I authorize Jackie J Consulting to share the information I provide with their partnered legal professionals for the purpose of evaluating potential violations.
I understand a law firm will be in contact with me regarding my collection accounts if there are any violations.
I understand there are no upfront fees for this service and the law firm will be paid directly from any monetary settlement. I understand after funds are dispersed to the law firm I may be awarded up to $250 for this violation.
I understand that submitting this form does not constitute a client-attorney relationship and the law firm will contact me directly with an engagement agreement if violations are found.
Thank you for providing this Information.
Our team will review your responses to determine if the collector’s actions violate any applicable laws (e.g. the FDCPA, FCRA, or TCPA). If you requested assistance, we will reach out with recommended next steps. All information you provide will be kept confidential and used solely to assist you with addressing this debt collection issue.
How did you hear about us?
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Road to 750
Other
Were you referred by someone?
Put N/A if you you were not referred by anyone
If you are being contacted by additional debt collectors, submit a separate form for each one.
*
I understand
I understand that I may receive monthly marketing emails from Jackie J Consulting regarding debt collector and creditor illegal practices and how to protect myself against them.
*
I understand
Privacy Disclaimer
At Jackie J Consulting we value your privacy and we are committed to protecting your personal information. All the information you provide in this form will be kept strictly confidential and will only be used to evaluate your eligibility for our free debt remediation program. Your data will never be sold or shared with third parties without your explicit consent, except as required by law. We implement appropriate measures to ensure the security of your information, protecting it against unauthorized access, alteration, or misuse.
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