Rausch, Sturm, Israel, Enerson & Hornik, LLC

Attorneys in the Practice of Debt Collection

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.

Please provide the following contact information:

*Name:
*Street Address:
Address(cont):
*City:
*State:
*ZIP:
*Home Phone:	()-
*Main Work Phone:	()-
*Mobile Phone:	()-
*Email:
*Confirm Email:
Preferred contact?:	HomeWorkMobileEmail

*Your file# with our office:
*Name of the creditor you owe:

Settlement Offer:

Lump SumPayment Plan

This is an amount that you would like to offer our client as payment in full on your account. This offer is not yet accepted by our client. Please do not make payment until we advise that it has been accepted. If accepted, the amount will need to be paid in full to our office in one installment. We will advise you of the deadline for payment. If payment is not received in our office by that time, the full balance will become due, less any partial payment applied.

*Amount You are offering as lump settlement: $
*Date by which you will pay the amount entered:	//
Additional Information or Comments:

Authorization: I understand that this offer of settlement or proposal for a payment plan is not effective until Rausch, Sturm, Israel, Enerson & Hornik, LLC. communicates acceptance of my offer or proposal. I declare that the information on this page and the proceeding pages is accurate and truthful. 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 Rausch, Sturm, Israel, Enerson & Hornik, LLC. by their due date, or Rausch, Sturm, Israel, Enerson & Hornik, LLC., at its option, can declare the settlement offer or payment proposal withdrawn. I also understand that if any of the information submitted on this page is found to be false that Rausch, Sturm, Israel, Enerson & Hornik, LLC., at its option, can declare the settlement offer or payment proposal void and withdrawn.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. Rausch, Sturm, Israel, Enerson & Hornik, LLC. may contact me by email or mobile phone regarding this matter.

I understand and agree to all of the terms listed above.

This Firm is a Debt Collector.