Referral Request Form
YOUR INFORMATION IS CONFIDENTIAL AND SECURE


YES! I am seeking professional assistance with resolving my outstanding debt obligations, and I am happy to be referred to a trusted colleague that provides a similar service at a similar price.

In addition, I’m aware of my various options and I’ve concluded that negotiating settlements on my outstanding debts is the best solution for myself and my creditors.

By checking this box I am confirming that I meet all of the following 4 conditions:

  • LEGITIMATE HARDSHIP. I understand that I must have experienced a legitimate hardship which contributed to my financial predicament. Examples of legitimate hardship would be loss of employment, divorce, health problems, etc.
     
  • MINIMUM DEBT TOTAL OF $15,000. I understand that I must have a total of at least $15,000 in unsecured debt (i.e. credit cards, department store cards, medical bills, etc.) to become a client.
     
  • SUFFICIENT FUNDS. I understand that I must have the ability to gather sufficient funds for settlement purposes within 24 months or less.
     
  • CREDIT SCORE WILL BE AFFECTED. I understand that my credit score will be adversely affected. However, I am willing to accept this trade-off in return for substantial debt relief without the need to file bankruptcy.

     

 Please complete the form below ...

 

 

 

 

 

 

 Current Situation

 

 

 

 

 

 

  What is motivating you right now to take action and resolve your present financial predicament?

  (please check all that apply)

 

 

 

 

 

 

 

I’m on the verge of filing bankruptcy, however I would first like to attempt a voluntary workout plan with my creditors with the limited funds that I have available.

 

 

 

 

 

 

 

I’ve tried consumer credit counseling and it’s not solving my problem.

 

 

 

 

 

 

 

I want to re-finance my mortgage or apply for a home loan, but I first need to settle some old debts before my loan can be funded.

 

 

 

 

 

 

 

I’ve had lingering past due debts for an extended period of time, but now I have some money to work with and I would just like to get these matters resolved once and for all because I know they’re not going to magically disappear.

 

 

 

 

 

 

 

I am sick and tired of the bill collectors calling constantly.

 

 

 

 

 

 

 

I’m being threatened with a lawsuit by one or more of my creditors.

 

 

 

 

 

 

 

Other. Please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

  How many different matters (i.e. accounts) need to be resolved?

 

 

 

 

 

 

 

 *required

 

 

 

 

 

 

  What is the grand total (approximately) of all your unsecured debts? (Must be at least $15,000)

 

 

 

 

 

 

 

 *required

 

 

 

 

 

 

 

 

 

 

 

 

  How far past due are your accounts?

 

 

 

 

 

 

 

0-3 months

 

 

3-6 months

 

 

 

 

 

 

 

 

6-12 months

 

 

more than 12 months

 

 

 

 

 

 

 

 

None of my accounts are past due.

 

 

 

 

 

 

 

 

 

 

 

 

  Please describe the event(s) that caused your present financial hardship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Have you considered filing bankruptcy?

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

If yes, what is the reason that you haven’t filed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 What additional questions or concerns (if any) do you still have?

 

 

 

 

 

 

 

 

 

 

 

 

 

 Settlement Objectives

 

Assuming your creditors would agree to settle your outstanding debts for $0.50 on the dollar or less, are you able to secure sufficient funds to honor such settlements?

 

 

 

 

 

 

 

Yes, definitely.

 

 

 

 

 

 

 

No, that would be totally impossible.

 

 

 

 

 

 

 

Probably.

 

 

 

 

 

 

What would be your strategy for securing the necessary funds to attempt negotiated settlements with your creditors?
(please check all that apply)

 

 

 

 

 

 

 

I am able to re-finance my mortgage or get a home equity loan.

 

 

 

 

 

 

 

A friend or family member is able to loan me the money (then I will make arrangements to pay them back privately).

 

 

 

 

 

 

 

I would be willing to liquidate (or take a loan against) my retirement account.

 

 

 

 

 

 

 

I have property that I could sell to raise the necessary funds (i.e. car, boat, real estate, stamp collection, etc.).

 

 

 

 

 

 

 

I would set aside a certain amount of money each month and accumulate funds to settle my debts, one by one, as funds became available.

 

 

 

 

 

 

 

What amount
per month?

 

 

 

 

 

 

 

 

 

Other. Please explain.

 

 

 

 

 

 

 

  What would be the time frame for securing these funds for settlement purposes?

 

 

 

 

 

 

 

0-6 months

 

 

6-12 months

 

 

 

 

 

 

 

 

12-24 months

 

 

24-36 months

 

 

 

 

 

 

 

 

Funds are available right now.

 

 

 

 

 

 

 

 

 

 

 

 

 Contact Information

 

 

 

 

 

 

First Name :

 *required

Last Name :

 

Email :

 *required

Phone (daytime #) :

 *required

State Abbreviation :

 *required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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