Creditor:

  Address:

  City:       

  State:    

  Zip Code:

  Phone:  

  Email Address:

  Authorized by:

  Debtor's Full Name:

  Address:

  City:       

  State:    

  Zip Code:

  Phone:  

  Previous Address:

  Employment:

  Employment Phone:

  SSN:       

  Date of Birth:

  Name of Spouse:

  SSN of Spouse:

  Amount Due:

  Account Number:

  Date Account Was 30 Days Past Due:

  Check ones that apply: Joint              Not Disputed     Mail Was Not Returned

                                           Individual     Disputed            Mail Was Returned

     or   Copy this from and Email it to glenn@txcredit.com