| Client Debt Collection Abuse Intake Form |
| Client Account Number : |
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| Card Holder's Name : |
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| State : |
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| Contact Date : |
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| Original Creditor : |
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| Have you been sued by this Creditor? |
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| Debt Collector : |
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| Individual Calling : |
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| Phone # of Caller : |
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| Date of Abuse : |
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| Number of times called : |
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| Time : |
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| Contacted Persons Name : |
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| Contacted Persons Number : |
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| May we contact them : |
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| What happened? : |
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| Contacted Persons Name : |
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| Contacted Persons Number : |
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| May we contact them : |
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| What happened? : |
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| Contacted Persons Name : |
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| Contacted Persons Number : |
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| May we contact them : |
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| What happened? : |
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| Contacted Persons Name : |
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| Contacted Persons Number : |
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| May we contact them : |
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| What happened? : |
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| Contacted Persons Name : |
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| Contacted Persons Number : |
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| May we contact them : |
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| What happened? : |
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| What happened? : |
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| What happened? : |
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| What happened? : |
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| Please fill out information below if you know it, thank you. | |||||||||||
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