Debtor's Name Debtor's Name The individual or business that owes money. Do you know the Debtor's Mailing Address? Do you know the Debtor's Mailing Address? YesNo Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Creditor's Name Creditor's Name The individual or business that is owed money. Do you know the Creditor's Mailing Address? Do you know the Creditor's Mailing Address? YesNo Enter the Creditor's Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Original Debt Amount Original Debt Amount $ Settlement Amount Settlement Amount $ This is the new amount the Debtor will pay. Payment How will the Settlement Amount be paid? How will the Settlement Amount be paid? Immediate PaymentScheduled PaymentsOther Scheduled Payments will be made on a Scheduled Payments will be made on a Daily basisWeekly basisMonthly basisQuarterly basisYearly BasisOther Scheduled Payments will be made: Due every Due every MondayTuesdayWednesdayThursdayFridaySaturdaySunday Due on the 1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30thof every Month What will be the Scheduled Payment? $until the balance is paid. If this Agreement is signed, when is the LAST DAY the Debtor can make payment? Also known as the "Payment Date". Usually is 30 days from the Agreement Date. Payment shall be made in the following manner: Interest Rate What will be the Interest Rate? % Numerical ONLY Late Fee Will there be a Penalty for any Late Payment? Will there be a Penalty for any Late Payment? YesNo If there is a Penalty, the Debtor will be obligated to pay the Original Debt Amount with the remaining balance to accrue at the maximum allowable interest rate under State law. Credit Report After the Debt is paid, will the Creditor be obligated to inform Credit Reporting Agencies? After the Debt is paid, will the Creditor be obligated to inform Credit Reporting Agencies? YesNo Such as Experian, Equifax, and TransUnion Effective Date What is the Effective Date of this Agreement? Governing Law This Agreement shall be governed by the laws in the State of Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming Additional Terms & Conditions Are there any Additional Terms and Conditions? Are there any Additional Terms and Conditions? YesNo Enter "Yes" if there were Terms or Conditions that were left out of this Agreement. Enter Next Save Save and finish later
