Request a Payment Plan

* Designates a required field.

File Number (WWR Number)

First Name *

Last Name *

Street Address *

City *

State *

Zip *

Telephone *

Last Four of SSN *

Proposed Monthly Payment Amount *

Proposed Monthly Due Date *

Additional notes regarding details of proposed payment plan:

Employment Status *

Employer Name *

Position Title

Employer Street Address

Employer City

Employer State

Employer Zip

Employer Phone

Gross Earnings

Pay Frequency *

Home Status *

Monthly Mortgage or Rent Payment *

Home Value

Amount Owed

Name of Mortgage Holder or Landlord

Automobile Owned?

Automobile Make

Automobile Year

Automobile Amount Owed

Name of Bank for Checking Account

Amount in Checking Account

Name of Bank for Savings Account

Amount in Savings Account

I agree to the Terms of Website Use and have read the State and Federal Disclosures.

I understand that upon receipt of the above information, a representative of Weltman, Weinberg & Reis Co., LPA may contact me by mail, telephone, or email to determine if the payment proposal can be accepted.

The submission of the above information does not represent an agreed payment plan until you are notified either verbally or in writing that a payment plan has been accepted.

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.