"Helping to navigate the troubled
waters of conflict."

Thursday 23 Feb 2012

Collections/Debt Mediation Intake Form

This form is for collections or debt mediation only - both residential and commercial. Please complete this form as thoroughly as possible. Use "N/A" if something is not applicable. Use "Don't Know" if you are unsure of the answer.

Preferred Date to Mediate:

1st Alternate Date:

2nd Alternate Date:

Preferred Session

If half-day requested, is there a preferred start time?

Have selected dates been confirmed by all the parties?

Yes
No
Don't Know

Please select the type of dispute:

What is the approximate debt amount?

What is the approximate debt amount? :: Enter the approximate amount owed in dollars

Your name as the individual that is completing this form:

Your involvement in the collections process:

Your involvement in the collections process: :: Please select the description that most closely relates to you.

Your contact phone number:

Your email address:

Court Information

Case Name or Style No.:

Cause No. (if any):

Court (if any):

Creditor / 3rd Party Agency Information

Creditor / 3rd Party Agency Name:

Creditor / 3rd Party Agency Name: :: This is the name of the company that is attempting to collect the debt.

Company Address:

Contact Name:

Contact Name: :: The name of the individual that is responsible for communicating with the debtor.

Contact Telephone #:

Contact Email Address:

Original Creditor (if different than above):

Borrower Information

Please complete all fields that apply to the borrower.

First Name

Last Name:

Company Name

Company Name :: If commercial case. If individual, this field is not required.

Mailing Address:

Primary Telephone #:

Secondary Telephone #:

Email Address:

Social Security Number / FEIN:

Date of Birth

Employer's Name:

Employer's Name: :: If you are self-employed, please type "self" and then the type of work you perform

Length of Employment (in years):

Gross Annual Income

Additional Income:

Additional Income: :: Please do not list your spouse's income unless it is separate from the Co-Borrower's income listed below. Alimony, Child Support or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying the debt.

Attorney's Name (if any):

Law Firm (if any):

Attorney/Law Firm Telephone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

Co-Borrower Information

Co-Borrower's Full Name:

Co-Borrower's Full Name: :: If there is no co-borrower, then please type "N/A"

Co-Borrower's Mailing Address:

Co-Borrower's Telephone Number:

Co-Borrower's Email Address:

Employer's Name:

Employer's Name: :: If Co-Borrower does not currently work, please type "N/A" here.

Length of Employment (in years)

Gross Annual Income:

Additional Income

Additional Income :: Please do not list your spouse's income unless it is separate from the Borrower's income above. Alimony, Child Support or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying the debt.

Attorney's Name (if any):

Law Firm (if any):

Attorney/Law Firm Telephone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

Please provide any additional details or information which you feel might be important for the mediation process:

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Resources

Resources for Court Officials

For more information about conflict management or to schedule a mediation, please give us a call at:

(469) 293-4237

We are available 24 hours a day to assist you with your dispute resolution needs!