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File Number (WWR Number)

First Name *

Last Name *

Street Address *

City *

State *

Zip *

Telephone Number *

Type of Inquiry:

Input the phone number to stop calls

Input full address to stop sending communication

Input full address and phone numbers to stop calling

Please provide date of death

Date Amount Whom did you pay

Provide details of the specific charge

Please provide description of the identity theft claim, or fraud claim. If possible, dates, amounts and if a police report is available.

Case * Chapter * Date Filed * State filed * Attorney Name Phone Number

Attorney Name * Attorney Address * Attorney Phone Number * Firm Name

Date * Amount * Check number or Money Order Number * Are you able to provide a copy of payment?

Additional Details

Amount Proposed * Due Date * Additional Details

Phone number where calls are being received Name of person

Please describe

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I understand that upon receipt of the above inquiry information, a representative of Weltman, Weinberg & Reis Co., LPA may contact me by mail, telephone, or email.

This communication is from a debt collector attempting to collect this debt for the current creditor and any information obtained will be used for that purpose.