Predatory Debt Discharge Intake

Dispute Preparation

Debt Discharge Survey

First Name *

Last Name *

Email *

Name of Business *

Phone Number *

Lender / Funder Name *

Original Loan / Advance Amount *

Current Estimated Balance *

Current UCC Filings Attached? *

Excessive Repayment Terms?

Daily Withdrawals Causing Financial Harm?

Misrepresentation of Loan Terms?

Unauthorized Debits?

Harassment or Deceptive Collection Tactics?

Additional Notes

Upload all documents available. UCC filings are required if you selected Yes for current UCC filings.

Original Contract and Funding Agreement *

Bank Statements Showing Daily Debit History *

Communication Records *

UCC Filings

Records of Collection Attempts *