Debt Collection Defense Intake Form

Check all that apply:

Undergraduate Student

Graduate Student

ASUM Employee

ASUM Senate Member

Lawsuit Filed? *

Yes

Date filed:

Month

Day

Year

Date Served:

Month

Day

Year

Last Payment on Account:

Medical Debt?

Yes

If yes, married at time debt incurred?

Received any notices from debt collector? *

Defenses:

Don't Owe

Wrong Amount

Past Sol

Disputed

FDCPA Violations:

Received a "Pre-Collect Memo"?

Yes

Monthly Income Sources: *

If not working, will you be employed again sometime in the future?

Assets:

House

Car

Bank Accounts

Other

You will be notified as soon as possible how we are able to assist you. If you are given an appointment, this does not mean that you have retained us to represent you as your attorney. If we are able to represent you then we will sign a Retainer Agreement and you will pay an additional retainer fee. You are responsible for any legal requirements, deadlines and hearings. Sign your understanding: *