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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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