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Referral Request Form
YOUR INFORMATION IS CONFIDENTIAL AND SECURE
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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.
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By checking this box I am confirming that I meet all of the following 4 conditions:
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- 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.
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Please complete the form below ...
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Current Situation
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What is motivating you right now to take action and resolve your present financial predicament?
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(please check all that apply)
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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.
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I’ve tried consumer credit counseling and it’s not solving my problem.
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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.
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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.
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I am sick and tired of the bill collectors calling constantly.
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I’m being threatened with a lawsuit by one or more of my creditors.
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Other. Please explain:
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How many different matters (i.e. accounts) need to be resolved?
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*required
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What is the grand total (approximately) of all your unsecured debts? (Must be at least $15,000)
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*required
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How far past due are your accounts?
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0-3 months
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3-6 months
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6-12 months
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more than 12 months
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None of my accounts are past due.
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Please describe the event(s) that caused your present financial hardship:
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Have you considered filing bankruptcy?
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Yes
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No
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If yes, what is the reason that you haven’t filed?
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What additional questions or concerns (if any) do you still have?
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Settlement Objectives
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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?
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Yes, definitely.
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No, that would be totally impossible.
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Probably.
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What would be your strategy for securing the necessary funds to attempt negotiated settlements with your creditors?
(please check all that apply)
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I am able to re-finance my mortgage or get a home equity loan.
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A friend or family member is able to loan me the money (then I will make arrangements to pay them back privately).
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I would be willing to liquidate (or take a loan against) my retirement account.
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I have property that I could sell to raise the necessary funds (i.e. car, boat, real estate, stamp collection, etc.).
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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.
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What amount
per month?
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Other. Please explain.
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What would be the time frame for securing these funds for settlement purposes?
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0-6 months
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6-12 months
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12-24 months
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24-36 months
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Funds are available right now.
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Contact Information
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First Name :
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*required
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Last Name :
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Email :
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*required
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Phone (daytime #) :
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*required
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State Abbreviation :
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*required
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