Credit Repair Form Name First Middle Last PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OccupationEmployment StatusEmployedRetiredName of Creditor or Collection Agency with whom you have a dispute. (To add additional names, click the "+" icon)Summary of your dispute/issue:Is this debt a consumer debt?YesNoAmount of total debt for goods, services or other:Date contract was entered: Date last payment was made: Has a lawsuit been filed?YesNoIf a lawsuit has been filed list the names of the parties, the Court where filed, case number, opposing counsel’s name and contact information, and the amount requested.If a lawsuit was filed, were the parties served?YesNoType of lawsuit filed:CollectionForeclosureGarnishmentReplevinOtherIf any legal proceedings have been filed, please upload the following Supporting Documents or email to email@example.com. • Lawsuit or other court paperwork, including but not limited to garnishments. • Last account statement received • Any recent correspondence • Copy of Contract for goods or services and other paperwork received. • Repair orders or receipts • Pictures State desired result, if applicable, i.e. cease and desist, pay debt, settle debt, enforce contract, invalidate contract, receive property or value of property, vacate judgment, or other remedy.Please tell us about any hardships that have occurred that affect your ability to pay the debt.Please tell us about any defenses you have to the payment on the contract, if applicable, i.e. improper service, mistaken identity, identity theft, statute of limitations, payment, amount disputed, lack of authority for plaintiff to sue, bankruptcy, unlicensed debt collector, or other excuse to contract enforcement or payment.How did you hear about the Royal Legal Group, LLC?WebsiteInternet searchHyatt Legal PlansARAG Insurance GroupBNIOtherPlease describe how you heard about the Royal Legal Group, LLC below:Disclaimer: If you are sending information and documents to the Royal Legal Group LLC to be reviewed in order to determine if the Royal Legal Group LLC can represent you, the sending of such information and/or documents does not indicate a lawyer-client relationship but merely provides the Royal Legal Group LLC with a means for assessing your case or matter. Such information may also be used to begin drafting any relevant documents necessary to handle your matter.* Yes, I Agree PhoneThis field is for validation purposes and should be left unchanged.