Debt Validation Form - Diverse Industries Inc

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Use this form to request validation of a debt from a creditor or collection agency. Under the Fair Debt Collection Practices Act (FDCPA), you have the right to request verification of any debt.

Important: Send this form via certified mail with return receipt requested. Keep copies of all correspondence for your records.

Debt Validation Request

Your Information

Full Name *

Address *

City *

State *

ZIP Code *

Creditor/Collector Information

Creditor/Collection Agency Name *

Address *

City *

State *

ZIP Code *

Debt Information

Account Number (if known)

Amount Alleged Owed *

Date of Original Debt

Original Creditor (if different from above)

Validation Requested

Please confirm the following information:

Verification of the debt amount

Proof that I am the responsible party

Copy of the original contract/agreement

Documentation of debt assignment (if applicable)

Proof of licensing to collect debts in my state

Additional Information

Any additional information or context

Declaration

I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.

Date *

Signature *

Next Steps

After completing this form:

Print a copy for your records
Send the original via certified mail with return receipt requested
Keep proof of mailing and delivery
Wait 30 days for a response
If no response, consult with a legal professional

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