Use this form to propose a settlement or payment plan on your account!

Wish to make a payment instead?  Click Here

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. 

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Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

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Your file number with our office:

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Name of the creditor you owe: 

Lump sum settlement offer: (Payment proposal form is below)

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. 

bulletAmount you are offering as a lump sum settlement: $
Enter dollars and cents please.
bulletDate by which you are proposing to pay the settlement in full :
(please use mm/dd/yy format)
bulletAdditional Information or Comments:

Payment plan proposal: (Settlement Offer form is above)

This is a proposal for payments over time at an agreed amount per payment.  Your proposal is not binding on our client or our office unless it has been accepted, and you keep the proposal by making all payments in a timely fashion.  We will advise you if your payment plan proposal has been accepted, and when your payments are due.

bulletAmount you are offering as a payment: $
Enter dollars and cents please.
bulletDate payments will commence:
(please use mm/dd/yy format)
bulletFrequency of payments:
 
bulletAdditional Information or Comments:

bulletAuthorization: I understand that this offer of settlement or proposal for a payment plan is not effective until Rausch, Sturm, Israel & Hornik, S.C. communicates acceptance of my offer or proposal.  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 & Hornik by their due date, or Rausch, Sturm, Israel & Hornik, at its option, can declare the settlement offer or payment proposal 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 & Hornik may contact me by email regarding this matter.
Please select appropriate choice: (you must pick one)
  Yes, I do understand and agree to all of the terms above.
            You may contact me by email regarding this matter.
  No, I don't agree to these terms above.
bulletConfirmation: After submitting this form you will see a confirmation page that you can print out to keep for your records.