Tell us what happened.
If your rights were violated, under the Fair Debt Collection Practices Act ("FDCPA") you may be entitled to up to $1000, plus costs and attorneys fees.
Information About You
Your Name *
Your answer
Your Phone Number *
Your answer
Your Email Address
Your answer
Your Zip Code *
Your answer
Debt Collector Information
The "Debt Collector" is the company that contacted you to collect the alleged debt.
Name of Debt Collector
Your answer
Debt Collector Phone Number
Enter all phone numbers that you have for the Debt Collector above.
Your answer
Debt Collector Email or Web Address
Your answer
Initial Contact *
Enter the first date you were contacted and how. (ex. 2/29/2016 by phone)
Your answer
Debt Collector Conduct
Did the Collector do any of the following:
Debt Collector Conduct (continued)
Tell us what happened in your own words. Include dates if you can.

Please keep it brief (under 5 sentences), as you will not be able to SUBMIT this form if you write too much. We will contact you to learn more.

Your Summary *
ex. "On 11/4/2015 Acme Debt Collector Inc. called me after 11:00P.M. and threatened to get me arrested."
Your answer
Original Creditor Information
The "Original Creditor" is the organization who first held the account. (ex. TD Bank, Gold's Gym, Juniper Hospital, Nissan etc.)
Name of Original Creditor *
Write "N/A" below and skip to SUBMIT if you do not know the Original Creditor.
Your answer
Kind of Account
ex. Credit Card, Gym Membership, Hospital Bill, Personal Loan etc.
Your answer
Was the Account used for Business
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This form was created inside of Charles Pascal Cohen.