FOR DEBTORS

THIS LAW FIRM IS A DEBT COLLECTOR. IF YOU ARE A DEBTOR CONTACTING THIS LAW FIRM, ANY INFORMATION OBTAINED WILL BE USED FOR DEBT COLLECTION PURPOSES.

This form may be used by you to PROPOSE a payment installment agreement that works for you. If you would like to propose an installment payment agreement, you will be contacted and informed if the proposed agreement is acceptable.

Your Proposal

Your Name:
Your account/reference account number:
Your creditor:
Your employer:
Proposed amount to be paid:
Start Date:

If you would like a reply to your proposed payment schedule by telephone, please provide your current telephone number:

Phone:

If you would like a reply to your proposed payment schedule by email, please provide your email address:

Email:

If you would like a reply to your proposed payment schedule by US mail, please provide your current address:

Line 1:
Line 2:
Town:
State: Zip:

Notice: This law firm is a debt collector. If you are a debtor and are contacting this office regarding a debt owed to one of our clients, we are attempting to collect that debt. Any information obtained may be used for debt collection purposes.

Patricia S. Rosenberg

P.O. Box 265

West Simsbury, CT 06092

860-651-7063

Patricia.Rosenberg@sbcglobal.net