Rossi Law Offices, LTD

TO PROPOSE A PAYMENT PLAN

Please complete the following to propose a payment plan. You will receive a reply from us on whether your proposal is approved.

*All fields must be filled in*

Your Name:
*Your Address:
 

*Your address as it appears on your correspondence from us.

Your Phone Number:
Our account number:
Your Email Address:
Update Address:
(if different than above)

YOUR PROPOSED PAYMENT PLAN:

Payment Amount:
Payment Frequency:
First payment due date:
Are you currently employed?
Yes No
Employer Name:
Number of dependents:
Are you receiving any form of public assistance?
Yes No
Do you receive social security benefits?
Yes No
Do you own any real estate?
Yes No

**GO PAPERLESS!!

Would you like to receive your monthly payment reminder statements via secure email?
Yes No

At this time we are not able to send weekly reminder statements.

Please provide us with any further information that you think maybe be helpful.

 

Comments:

 

This is an attempt to collect a debt. Any information obtained will be used for that purpose. This communication is from a debt collector.

 

 

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