Creditor Name
First Address Line
Second Address Line (if needed)
Third Address Line (if needed)
City
State
Zip
Acct. No. (last 4 digits only)
Started what year
2008-2009
2006-2007
2004-2005
BEFORE 2004
VARIOUS
Amount owed. Whole dollars, no cents, no periods, no dollar signs, no commas. Example: if you owe $7,146.39, write 7146.
What for
CREDIT CARD
MEDICAL
LOAN
STUDENT LOAN
UTILITY
GOODS/SERVICES
COLLECTION AGENCY
LAW FIRM
BUSINESS
OTHER
Your three initials (use your same initials for every creditor)
Look up address