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IF YOU ARE REPRESENTED BY AN ATTORNEY YOU CANNOT
SUBMIT THIS FORM, BUT INSTEAD MUST HAVE YOUR
ATTORNEY CONTACT OUR OFFICE.
This Form Is To Request A Payment Plan ONLY IF SUIT HAS
ALREADY BEEN
FILED AGAINST YOU.
It Is Only A Request, And You Will Be Notified Whether It Is
Ultimately Accepted Or Denied. If It Is Accepted You Will
Receive A Consent Order To Sign And Return. If You Make
A Payment Prior To Acceptance, It Will Simply Be Considered
A Partial Payment On Your Total Balance Due.
This Law Firm Is Deemed A 'Debt Collector' Under The
Fair Debt Collection Practices Act. We Are Attempting To Collect
A Debt, And Any Information Obtained Will Be Used For
That Purpose.
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PROPERTY INFORMATION
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| Subdivision Name: | * |
| Street Address: | * |
| City: | * |
CONTACT INFORMATION
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| Full Name: | * |
| Street Address: | * |
| City: | * |
| County: | * |
| State: | * |
| Zip Code: | * |
| Email Address: | * |
| Cell Phone: | |
| Home Phone: | |
PAYMENT PLAN
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If Your Total Balance Due Including Attorney Fees Is
Less Than $1,200.00, Payments May Not Be
Extended Beyond 12 Months
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| Down Payment: | * |
| Payments: | * |
| Any Comments: | |
By Checking The Box Below, I Certify That I Am Not
Represented By An Attorney, But I Am Instead
Representing Myself And Give Explicit Permission
To Be Contacted Directly By Rome & Associates, PC
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| I Agree To The Above: | * |
By Submitting This Request I Understand That $50
In Atty Fees Will Be Added To My Account For
Drafting The Consent Order And Another $50 For
Processing The First Six Installments,
and $50 For Each Additional
Six Months Or Fraction Thereof.
In Addition, Interest Will Be Added At The
Allowed Annual Rate.
I Further Understand That Simply Requesting
A Payment Plan Will Not Result In
The Cessation Of Collection Efforts.
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| To prevent automated SPAM, please enter 3LGR to submit your form (case sensitive): | * |
* indicates required field
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