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.

If you or a family member are Active Military Duty you may be eligible for additional relief, please refer here for further information.

I acknowledge that:

• I have read the Privacy Notice
• 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