Debt Settlement Company Submission

This page is intended for use by a Debt Settlement Company.

Toll-Free Phone Number

(888) 533-0660

-
Dial 711 for TRS

Fax

Mailing Address

Glasser and Glasser, P.L.C.
P.O. Box 2458
Norfolk, VA 23501

Debt Settlement Company Information

Account Information

Date of Birth

(mm/dd/yyyy)

Last 4 of SSN*

Power of Attorney Document*

By submitting this form, you consent to our office contacting you at the e-mail address and phone number provided and you acknowledge that the e-mail address and phone number provided are private and not used for business purposes.*

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This is a communication from a debt collector. This is an attempt to collect a debt. Any information obtained will be used for that purpose. Completing this form does not establish an attorney-client relationship. We value the privacy and security of your information.

Protect your personal information and do not send confidential information using this form such as your full social security number or payment account information.

We may not be able to discuss the specifics of your account via email.