Payment Plan Application

To apply for a payment plan, please complete this form and press the send button. Your answers to these questions help our client better understand your ability to pay. We will respond to you promptly. Thank you.

Required fields are marked with an asterisk (*).
Incomplete applications cannot be considered.

* First Name:
* Last Name:
Do you have a file number?	(Ex. Number: 00-00000)
* Date of Birth:	Please enter date in a mm/dd/yyyy format
* Last four digits of Social Security No:
* Street Address:
Apt. No.
*City:
*State:
*Zip Code:
*Telephone No.:
Cell phone No.:
*Email address:
*Are you employed:	-Yes -No
Full time or part time:	-Full -Part -N/A This is a required field when you are employed. Please select an option other than N/A when employed.

Employer Information

* Employer Information is required when you indicate that you are employed.
*Name of Employer(s):
*Street Address :
Suite No:
*City:
*State:
*Zip Code:
*Phone:
*Date of Hire:	Please enter date in a mm/dd/yyyy format
*Can you receive calls at work?	-Yes -No
*How often are you paid?	-Weekly -Bi weekly -Monthly -N/A Please select an option other than N/A when employed.
* Hours worked per pay:
*Average take home pay (per pay period, after taxes):	$
*Please indicate the period being used to report your salary:	-Weekly -Bi weekly -Monthly -Yearly -N/A Please select an option other than N/A when employed.

Are your wages currently being attached or garnished?	-Yes -No
If yes, is the wage attachment for child support?
If you are not employed, please indicate if you receive child support, unemployment compensation, disability income insurance, alimony, SSI or other assistance?
Are you in the military?	-Yes -No
Are you a veteran?	-Yes -No
Rent payment per month	$
Landlord’s Name
Landlord’s Address
Landlord’s Telephone Number
Mortgage payment per month	$
Is mortgage being paid on time?	-Yes -No -N/A
*Which day of the month would you prefer to make payment (select 1st through 28th)?: *How much can you realistically afford to pay per month? How much time do you need to pay this debt?
If you need more room to complete an answer, or would like to add additional information about your financial situation, please enter below.
I certify that the foregoing statements are true and correct, and authorize the continuing verification of the information contained herein. You may contact me by E-mail.
* Signature: (type full name) * and Dated:

   

This communication is an attempt to collect a debt and any information obtained will be used for that purpose. This information is not intended to be legal advice. If you have questions, please consult an attorney.