Debt Collector Intake

  • 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

  • Format: (000) 000-0000.
  • Date of Birth *
     - -

  • Section 2: Debt Collector Details

  • Date of Last Payment to Original Creditor?
     - -
  • Do you think you owe this debt?*
  • Have you already paid this debt (partially or in full)*
  • If you have already paid this debt, what date was it paid?
     - -
  • How did you first learn about or hear from this debt collector?*
  • Have you ever told the debt collector that you dispute the debt ?*
  • If you disputed the debt, did you do so in writing? (e.g. sending a letter or email to the debt collector)*
  • If you disputed this debt, when did you dispute?
     - -
  • After you disputed the debt, did the debt collector provide proof of the debt or stop contacting you about it?*

  • Section 3: Communication and Contact Methods

  • Contact Methods: How does this debt collector typically contact you? (check all that apply).*
  • 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.)*
  • 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)*
  • Contact at Work: Has the debt collector ever contacted you at your workplace or called you on a work number?*
  • 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)?*
  • 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.)*
  • If you asked the debt collector to stop contacting you, when did you make the request?
     - -
  • 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).*

  • 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)*

  • Section 5: Credit Reporting

  • Is this debt showing on your credit report? (e.g. Experian, Equifax, or TransUnion report).*
  • If yes, is the information about the debt on your credit report accurate (correct amount, status, dates, etc.)?*
  • Have you disputed this debt through the credit bureau(s)?*

  • Section 6: Next Steps

  • Do you want this debt collector to stop contacting you?*
  • Would you like help with this?*
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  • Check each box below that you agree and understand:*

  • 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.

  • 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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