top of page

This form must be submitted to us within 30 days of receiving your notice.  The 30-day date can be found on your initial letter from us in the following paragraph:

   Example:  Unless you notify this office by phone or in writing by (30 days date) that you ......

If you notify us by the 30-day date, we must stop collection of the account until we provide you with the requested information below.


Section 1:  Complete with all requested information.  The Debtor & Account Number is located on the letter in the top right under your name and address.

Section 2:  Choose one or both options.  We will send you the requested information via mail.

This communication is from a debt collector and this is an attempt to collect a debt.  Any information obtained will be used for that purpose. 

Section 1 - Personal Information

Section 2 - Consumer Response Request

            How do you want to respond?  Check all that apply.

I want to dispute the debt because I think:
Send me the following:

Click the submit button below when you are completed with this form.

Thanks for submitting!

bottom of page