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Account Holder Information & Proposed Settlement Form

Please complete as many of the fields below as you can. The more information we have, the better we will be able to represent your information to our client and promptly resolve this matter.

Thanks in advance for choosing to deal with your debt without further delay!

Account Holder Information

This is YOUR information or information regarding the company or organization that owes our client money.

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Account Holder’s Name*
Company or Organization Name If you are completing this form on behalf of a company or other organization, please enter the name of the organization here.
Is the person submitting this form the account holder listed above?*	Yes No
Name of Person Submitting This Form*
Would you like to propose a settlement or payment arrangement?*	Yes No
Debski & Associates file number, if known (i.e. N09000XX)
Address*
City*
State*	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*
Date of Birth*
Home Telephone Number	- -
Wireless(Cell) Phone Number	- -
Fax	- -
Your Email
Employer Name
Complete Employer Address
Number of Months You Have Been Employed by This Employer
Your Job Title
Your Income	$
Salary or Hourly?	Salary Hourly
Other Sources of Monies Received (i.e., include, social security, pension & child support)
Amount of Funds You Receive Monthly From Any Source	$
Do you own your home or rent?*	Own Rent
Are you married?	Yes No
Spouse's Job Title
Spouse's Income	$
Spouse's Income Hourly or Salary?	Salary Hourly
Do you have any children or other dependents that depend on you financially?*	Yes No
What is your total combined annual household income?	$
Additional Information
Creditor Information
Name of Creditor to whom YOU OWE money*
Creditor account number, if known
Be aware that your making a settlement or payment offer for consideration here DOES NOT obligate our client in any way whatsoever to accept your offer. Our office will contact you and let you know if your offer has been accepted. I agree
If you are offering a one time payment settlement offer, please do so here
Amount of sum to be paid
Date the payment is to be received in our office
If you are offering a settlement, state the source of the settlement funds: (i.e., savings, bank loan, friend/family)
If you are offering a settlement paid out over a few months, please do so here
Total amount you are proposing to pay
Dates and amounts of the payments you propose to make
If you are offering to make installment payments, please do so here
Amount of each installation payment
Would you rather pay weekly, monthly or bimonthly?	Weekly Monthly Bimonthly
Date the first payment is to be received in our office
Date the payment is to be received in our office each month or week
If there are any conditions or any other matter with regard to your offer that you would want our client to consider, please indicate what they are here
reCAPTCHA Security Code*
By submitting this form I am authorizing Debski & Associates, P.A. and its employees to contact me using the phone numbers, fax, and email address supplied above, including calling your wireless phone number on an automatic telephone dialing system.
*Required field