Federal taxes State taxes Social Security FICA Union duesInsurance payments Child support wage withholding Other mandatory deductions specify: Job 2: Gross pay, including overtime: $ Sub
Trang 1Utilities and telephone
Trang 2Medical (doctors’ and hospital) bills
Other unpaid bills
Trang 3s e r u t i d n p x
s
’ y a d r u t a S
s e r u t i d n p x
r e t O
s e r u t i d n p x
Trang 5Federal taxes State taxes Social Security (FICA) Union dues
Insurance payments Child support wage withholding Other mandatory deductions (specify):
Job 2: Gross pay, including overtime: $
Subtract:
Federal taxes State taxes Social Security (FICA) Union dues
Insurance payments Child support wage withholding Other mandatory deductions (specify):
Job 3: Gross pay, including overtime: $
Subtract:
Federal taxes State taxes Social Security (FICA) Union dues
Insurance payments Child support wage withholding Other mandatory deductions (specify):
Trang 6Monthly Income From All Sources (cont’d)
Amount of Period covered Amount
B Self-Employment Income
Subtract:
Federal taxesState taxesSelf-employment taxesOther mandatory deductions (specify):
Subtract:
Federal taxesState taxesSelf-employment taxesOther mandatory deductions (specify):
C Other Sources
Bonuses
Dividends and interest
Rent, lease or license income
Royalties
Note or trust income
Alimony or child support you receive
Pension or retirement income
Trang 7I am writing to dispute the following charge that appears on my billing statement dated
, 20 Merchant’s name:
Amount in dispute:
I am disputing this amount for the following reason(s):
As required by law, I have tried in good faith to resolve this dispute with the merchant [Describe your
ef-forts .]
Furthermore, I wish to point out that this purchase was for more than $50 and was made [cross out one:]
in the state in which I live/within 100 miles of my home
Please verify this dispute with the merchant and remove this item, and all late and interest charges attributed
to this item, from my billing statement
Trang 9I am writing to point out an error that appears on my billing statement dated ,
20
Merchant’s name:
Amount in error:
The problem is as follows:
I understand that the law requires you to acknowledge receipt of this letter within 30 days unless you correct
this billing error before then Furthermore, I understand that within two billing cycles (but in no event more
than 90 days), you must correct the error or explain why you believe the amount to be correct
Trang 11On , 20 , I received a copy of my credit report from
It lists my payments to you as delinquent
My past financial problems are behind me and I am now in a position to pay off this debt I can pay a
lump sum amount of $ or I can pay installments in the amount of $
per month for months if you will agree to either of the following:
If I make a lump sum payment, you agree to remove the negative information from my credit file
associ-ated with the debt
If I agree to pay off the debt in installments, you agree to re-age my account—that is, make the current
month the first repayment month and show no late payments as long as I make the agreed upon
monthly payments
If my offer is acceptable to you, please initial one of the above lines, sign the acceptance below and
return this letter to me in the enclosed envelope
Trang 13Total amount due:
Monthly payment amount:
To Whom It May Concern:
At the present, I cannot pay the monthly amount required under the agreement for the following reason(s):
I can pay $ per month right now and expect to resume making the full monthly payment
when the following occurs:
Please accept the reduced payments until then If necessary, add the unpaid amount to the end of the loan
or account period and extend it by a few months
Thank you for your understanding and help Please call or write within 20 days to let me know if this is
Trang 15Total amount due:
Monthly payment amount:
To Whom It May Concern:
At the present, I cannot pay the monthly amount required under the agreement for the following reason(s):
I can pay you only $ per month for the indefinite future Please accept the reduced
payments I promise to inform you immediately if my financial condition improves and I am able to resume
making normal payments
Thank you for your understanding and help Please call or write within 20 days to let me know if this is
Trang 17Total amount due:
Monthly payment amount:
To Whom It May Concern:
At the present, I cannot pay the monthly amount required under the agreement for the following reason(s):
For now, I cannot make any payments I expect to resume making the full monthly payment when the
following occurs:
If necessary, add the unpaid amount to the end of the loan or account period and extend it by a few months
Thank you for your understanding and help Please call or write within 20 days if this is unacceptable
Trang 19Total amount due:
Monthly payment amount:
To Whom It May Concern:
At the present, I cannot pay the monthly amount required under the agreement for the following reason(s):
Due to my desperate financial situation, I cannot make any payments for the indefinite future [Describe
Trang 21Total amount due:
Monthly payment amount:
To Whom It May Concern:
At the present, I cannot pay the monthly amount required under the agreement for the following reason(s):
I would like the terms of the loan rewritten in order to reduce the amount of the monthly payments
Thank you for your understanding and help Please call me as soon as possible in order that we may
discuss new loan terms
Trang 23Total amount due:
Monthly payment amount:
Collateral:
To Whom It May Concern:
I cannot pay the monthly amount required under my agreement with you I invite you to come pick up the
collateral, or to let me know where I can return it to you, if you can assure me in writing that the entire
debt will be canceled when the property is returned, and that I will not be liable for any deficiency
Trang 25Enclosed is a check for $ to cover the balance of the account Cashing this check
constitutes payment in full