Propose a Settlement or Payment Plan

In order to assure that your settlement offer or payment plan proposal is properly received and accurately applied to your account you must fully complete the top portion of this form, as well as either the Settlement Offer or Payment Proposal section of your choice. Your email address and phone numbers are critical to follow up should we need additional information from you. This firm is a debt collector. This is an attempt to collect a debt and all information obtained will be used for that purpose.

Debtor Information

File Number

Name

First and Last

Company

Address

Phone

City

State

Zip

Employer Information

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Financial Institution Information

Bank Name

Type of Account Type of Account

Name of Creditor you Owe

Lump Sum Settlement Offer

Offered Settlement Amount

Proposed Settlement Amount

Additional Information or Comments

Payment Plan Proposal

Amount of Payment Offered

Date Payments Commence

Dropdown

Authorization

I understand that this offer of settlement or proposal for a payment plan is not effective until BQ & Associates P.C. L.L.O communicates acceptance of my offer or proposal. In addition, I understand that if my offer or proposal is accepted, that all payments must be made in the agreed amount, and must be received by BQ & Associates P.C. L.L.O by their due date, or BQ & Associates P.C. L.L.O at its option, can declare the settlement offer or payment proposal withdrawn. In that event, the full remaining balance will be due, and any payment made on the account thereafter will be applied against the full balance. BQ & Associates P.C. L.L.O may contact me by email regarding this matter.

I understand and agree to the above.

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