Consent Order Request Form
IF YOU ARE REPRESENTED BY AN ATTORNEY YOU CANNOT
SUBMIT THIS FORM, BUT INSTEAD MUST HAVE YOUR
ATTORNEY CONTACT OUR OFFICE.
This Form Is To Request A Payment Plan ONLY IF SUIT HAS
ALREADY BEEN
FILED AGAINST YOU.
It Is Only A Request, And You Will Be Notified Whether It Is
Ultimately Accepted Or Denied. If It Is Accepted You Will
Receive A Consent Order To Sign And Return. If You Make
A Payment Prior To Acceptance, It Will Simply Be Considered
A Partial Payment On Your Total Balance Due.
This Law Firm Is Deemed A 'Debt Collector' Under The
Fair Debt Collection Practices Act. We Are Attempting To Collect
A Debt, And Any Information Obtained Will Be Used For
That Purpose.


PROPERTY INFORMATION
Subdivision Name:*
Street Address:*
City:*
CONTACT INFORMATION
Full Name:*
Street Address:*
City:*
County:*
State:*
Zip Code:*
Email Address:*
Cell Phone:
Home Phone:
PAYMENT PLAN
If Your Total Balance Due Including Attorney Fees Is
Less Than $1,200.00, Payments May Not Be
Extended Beyond 12 Months
Down Payment:*
Payments:*
Any Comments:
By Checking The Box Below, I Certify That I Am Not
Represented By An Attorney, But I Am Instead
Representing Myself And Give Explicit Permission
To Be Contacted Directly By Rome & Associates, PC
I Agree To The Above:*
By Submitting This Request I Understand That $50
In Atty Fees Will Be Added To My Account For
Drafting The Consent Order And Another $50 For
Processing The First Six Installments,
and $50 For Each Additional
Six Months Or Fraction Thereof.
In Addition, Interest Will Be Added At The
Allowed Annual Rate.
I Further Understand That Simply Requesting
A Payment Plan Will Not Result In
The Cessation Of Collection Efforts.
To prevent automated SPAM, please enter QXHW to submit your form (case sensitive):*
 

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