Debt Collection Intake Form

Debt Collection Intake Form
Please complete the following questions as thoroughly and accurately as possible. Your responses will help us better understand your situation and provide you with the most appropriate guidance and support.
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Birth Date
  
  MonthDayYear
  Date
- Are you getting contacted by a debt collector?
- How many debt collectors are contacting you?
- Do you recognize the account(s)?
- Is the account(s) on your credit report?
- Original Creditor`s Name
- Debt Collector`s Name
- Balance of Debt
- Date of Last Payment to Original Creditor
  
  MonthDayYear
  Date
- Have you made a payment to the debt collector?
- How did you first become aware of the collection account(s)?
  
  Other
- Have you disputed this account with the debt collector directly or credit reporting agency?
- If so, who did you dispute with? And what was your dispute reasoning along with the dispute method? If you hired someone to dispute, also provide those details below, along with when the account was disputed?
- How is the debt collector contacting you?
- Do you feel any of these contact methods were excessive, harassing, or intimidating?
- Have you been threatened with any of the following if you did not pay?
- Have they ever contacted you before 8:00am or after 9:00pm local time?
- Have they ever contacted you while at work?
- Have they ever contacted your employer, family member or friend?
- Do you want this debt collector to stop contacting you?
- Would you like help with this?
- Any additional information you would like to share.
- Upload any correspondence from the debt collector or any correspondence you sent.
  
  Cancelof
- Upload any correspondence from the debt collector or any correspondence you sent.
  
  Cancelof
- Upload any correspondence from the debt collector or any correspondence you sent.
  
  Cancelof
- How did you hear about us?
- Name any other accounts including charge offs!
- Should be Empty: