In order to assure that your payment is properly received and accurately applied to your account you must fully complete this form. Your address and phone numbers are critical to follow up should we need additional information from you. This firm is a debt collector. This is an attempt to collect a debt and all information obtained will be used for that purpose.
I ACKNOWLEGE THAT:
My account is not in dispute
I have not previously requested verification of my account
I am not represented by counsel
I am not a petitioner in any pending bankruptcy petition, and
This account has not been discharged in bankruptcy
I agree to discuss my debt online