Date: ______________________

Name(s) on account: ______________________

Account number: __________________________

Date loan/debt incurred: ____________________

Original loan/debt amount: __________________

Amount past due: _________________________

Re: Collection agency: [Collection agency name]

To Whom It May Concern:

I have been unable to pay the full amount of the loan/debt noted above for the following reason(s):

_____________________________________________________________________________

Although I have an outstanding debt, I have the right to be treated by a collection agency with dignity and respect. The collection agency you hired (and noted above), however, has engaged in the following practices, which violate the federal Fair Debt Collection Practices Act:

_____________________________________________________________________________

I am willing to forgo the legal remedies I have available, including a lawsuit in small claims court seeking punitive damages against you and the agency, in exchange for your written promise to permanently cease all efforts to collect this debt and remove all negative entries regarding this debt from my credit file. I expect to hear from you immediately.

Sincerely,

_________________________________________
[your signature]

Name:    ________________________
Address: ________________________
            ________________________
Home phone: ____________________

cc:    Federal Trade Commission
        State Collection Agency Licensing Board
        Collection Agency: [Collection agency name]