Propose a Settlement or Payment Plan

In order to assure that your settlement offer or payment plan proposal is properly received and accurately applied to your account you must fully complete the top portion of this form, as well as either the Settlement Offer or Payment Proposal section of your choice. Your email 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.

 
Debtor Information *Bold fields are required
File Number:
Name:
Company:
Address:
 
City:
State, Zip: ,
Phone:
Email:
   
Employer Name & Address:
   
Bank Name:
Type of Account:
   
Name of creditor you owe:
   
Lump Sum Settlement Offer:
Offered Settlement Amount:
Proposed Date of Payment:
   
Additional Information or Comments:
   
Payment Plan Proposal:
Amount of Payment Offered:
Date Payments Commence:
Frequency of Payments:
Additional Information or Comments:
   
Authorization: I understand that this offer of settlement or proposal for a payment plan is not effective until Brumbaugh & Quandahl, PC. communicates acceptance of my offer or proposal.  In addition, I understand that if my offer or proposal is accepted, that all payments must be made in the agreed amount, and must be received by Brumbaugh & Quandahl, PC by their due date, or Brumbaugh & Quandahl, PC, at its option, can declare the settlement offer or payment proposal withdrawn.  In that event, the full remaining balance will be due, and any payment made on the account thereafter will be applied against the full balance.  Brumbaugh & Quandahl, PC may contact me by email regarding this matter.