[City state ZIP]
[City State ZIP]
[Date] Certified Mail No.: _____________
Re: Inquiry dated ___: account no. (none)
Thank you for your recent inquiry. This is not a refusal to pay, but a notice that your claim is disputed.
This is a request for validation made pursuant to the Fair Debt Collection Practices Act. Please complete and return the attached disclosure request form.
Be advised that I am not requesting a “verification” that you have my mailing address, I am requesting a “validation;” that is, competent evidence that I have some contractual obligation to pay you.
You should also be aware that sending unsubstantiated demands for payment through the United States Mail System might constitute mail fraud under federal and state law. You may wish to consult with a competent legal adviser before your next communication with me.
Your failure to satisfy this request within the requirements of the Fair Debt Collection Practices Act will be construed as your absolute waiver of any and all claims against me, and your tacit agreement to compensate me for costs and attorney fees.
CREDITOR DISCLOSURE STATEMENT
Name and Address of Collector (assignee):
Name and Address of Debtor:
What are the terms of assignment for this account? You may attach a facsimile of any records relating to such terms.
Have any insurance claims been made by any creditor or assignee regarding this account?
Yes / no
Has the purported balanced of this account been used in any tax deduction claim?
Yes / no
Please list the particular products or services sold by the collector to the debtor and the dollar amount of each:
Upon failure or refusal of collector to validate this collection action, collector agrees to waive all claims against the debtor named herein and pay debtor for all costs and attorney fees involved in defending this collection action.
Authorized signature for Collector Date
Please return this completed form and attach all assignment or other transfer agreements that would establish your right to collect this debt.
Your claim cannot be considered if any portion of this form is not completed and returned with the required documents. This is a request for validation made pursuant to the Fair Debt Collection Practices Act. If you do not respond as required by this law, your claim will not be considered and you may be liable for damages for continued collection efforts.