Print, Fill out, send back
Please print, fill out and fax these forms to me at 206-203-4887, or print, fill out, scan, then email so that we can get started on your Free Debt Consultation today. Thank you for your time. NOTE: Fill out as much as you can, and an agent will help you with the rest. It is best to copy text from here and paste in microsoft word then print.
Forms for Debt Consultation.
BHR & Associates Bus. Voicemail & Fax: 206-203-4887
CLIENT INFORMATION SHEET
Confidential Information
Date Client Retained_____/_____/_____ Sales Rep:__________________________________________
Name of Client________________________________________________________________________________ Address_______________________________________________________________________________ City, State, Zip___________________________________________________________________________________
Contact Info.: Bus. (____)_________________Fax (____)________________________________ Home (____)________________Fax (____)________________________________ Cell (____)__________________E-Mail___________________________________
Contact: ______________________________________________________________________________________ Comments:____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
The retainer agreement, the release form and your creditor information must be sent along with this client information sheet in order to meet our debt program qualifications. All of your information is kept completely confidential.
BHR & Associates
112 Edgemont Dr. Princeton, WV 24740 Bus. Voicemail & Fax: 206-203-4887
Chris Dillon, Email: admin@chris-dillon.net.tf
RETAINER, AGENCY, and POWER OF ATTORNEY APPOINTMENT
I (please print name) ____________________________________________________________________________________________ residing at____________________________________________________City of___________________________________________ County of_____________________________________State of_________________Zip Code__________________________________
herby make, constitute, and appoint BHR & ASSOC., my agent and true and lawful attorney-in-fact, for me and in my stead giving unto
BHR & ASSOC., full power to do and perform all and every act that I may legally do through and attorney-in-fact and every power necessary to carry out the specific purposesfor which this power is granted. TO NEGOTIATE CREDITOR’S CLAIMS AND TO EFFECT A REASONABLE SETTLEMENT.NO LEGAL ADVICE CAN OR WILL BE PROVIDED UNDER THIS AGREEMENT. Separate legal counsel can be arranged.II
Our fee shall be established at the rate of 35% of savings per creditor claim. No fees will be charged or due until a settlement has been made, and then accepted by the client. This is always due and payable upon acceptance of the settlement(s).
III
This power of appointment shall provide a full working arrangement to effectuate legitimate settlements of all claims owing. The parties agree that this appointment does not create personal liability on the part of BHR & ASSOC., for the debts of the debtor; and/or for any entries to any credit reports of the debtor, and that this agreement carries an obligation on the part of the debtor to honor all negotiated settlements based on representation of the debtor and that BHR & ASSOC., is obligated to provide professional assistance to the best of its ability to effectuate reasonable settlements
IV
Our fee is due and must be paid upon verification and your acceptance of each individual settlement. The nature of our business does not allow us to offer you any type of credit terms. There is no flexibility in this respect. Non-payment within five business days from the date of delivery will automatically cancel the settlement. The only acceptable method of payment is through a bank wire transfer.
V
It is further understood and agreed that should legal action be brought to enforce this agreement, the prevailing party shall be entitled to attorney’s fees and costs.
VI
The undersigned agree that both parties may sever their relationship at any time upon giving reasonable notice. In such event, the client shall only be responsible for the fees incurred to the date of such severance.
Client:_________________________________________________ Agent:____________________________________________________
Date________________________________________________
BHR & Associates 112 Edgemont Dr. Princeton, WV 24740 Bus. Voicemail & Fax: 206-203-4887 Chris Dillon Email: admin@chris-dillon.net.tf
AUTHORIZATION TO RELEASE INFORMATION DATE: ______________________________________________________ TO: ______________________________________________________ RE: ______________________________________________________ ACCT. #: ______________________________________________________ ATTN: ______________________________________________________We have been retained by the above to manage their outstanding debts. Funds will be sent immediately to settle the above debt. Since there are limited funds with which to settle, priority is given on a first-come first-served basis, therefore, please contact me at the above number as soon as possible.
Sincerely,
Mark Berglas
The undersigned authorizes BHR & Assoc., to settle the above debt: _____________________________ ___________________________ Authorized Signature Social Security Number _____________________________ ___________________________ Please Print Name Date
LIST OF CREDITORS
Date Opened: ___________________ Rep: _Chris Dillon____ ACCOUNT NAME: _________________________________________________ Creditor #:____ ____________________ Amount Owed: _________ Address: _________________________________________________ City: ____________________ Contact: ____________________ A/C #: _______________________________ Phone: (_____) ______________ Fax: (_____) _________
Creditor #:__ ____________________ Amount Owed: _________ Address: _________________________________________________ City: ____________________ Contact: ____________________ A/C #: ______________________________ Phone: (_____) ______________ Fax: (_____) _________Creditor #:____ ____________________ Amount Owed: _________ Address: _________________________________________________ City: ____________________ Contact: ____________________ A/C #: ______________________________ Phone: (______) _____________ Fax: (______) ________
LIST OF CREDITORSDate Opened: ___________________ Rep: _____Chris Dillon___________ ACCOUNT NAME: _________________________________________________
Creditor #:____ ____________________ Amount Owed: _________ Address: _________________________________________________ City: ____________________ Contact: ____________________ A/C #: _______________________________ Phone: (_____) ______________ Fax: (_____) _________
Creditor #:___ ____________________ Amount Owed: _________ Address: _________________________________________________ City: ____________________ Contact: ____________________ A/C #: ______________________________ Phone: (_____) ______________ Fax: (_____) _________
Creditor #:____ ____________________ Amount Owed: _________ Address: _________________________________________________ City: ____________________ Contact: ____________________ A/C #: ______________________________ Phone: (______) _____________ Fax: (______) ________