DEBT COLLECTOR DISCLOSURE STATEMENT

Re: Offer to Perform Upon Validation of Debt

Notice to Respondeat Inferior is Notice to Respondeat Superior

Notice to Respondeat Superior is Notice to Respondeat Inferior

Claimant: yourfirst yourmiddle: house of YourLast for YOURFIRST YOURMIDDLE YOURLAST

Alleged Account Number: 0012345678
Alleged Amount: $10,000.00
Debt Collector: DEBT COLLECTORS, INC.

hereinafter, Debt Collector

By: Registered Mail Number: RE 000 000 000 US

NOTICE

Pursuant, but not limited to, the Fair Credit Reporting Act at [15 USC 1681 et seq.] and the Fair
Debt Collection Practices Act at [15 USC 1692 et seq.], and the applicable portions of Truth in Lending
(Regulation --- Z), at 12 CFR part 226 et seq., Debt Collector(s) are to complete and return this Debt Collection
Disclosure Statement", hereinafter "Statement," with all required documentary and evidentiary proofs stipulated
herein, in conjunction with the attached and incorporated herein "Offer to Perform Upon Validation of Debt"
within twenty-one (21) days of receipt by Debt Collector.

Should Debt Collector(s) fail or refuse to completely answer, in entirety, all points 1 through 41
below and returning this Statement, along with all supporting and associated documentation, constitutes Debt
Collector(s) tacit acquiescence that Debt Collector(s) and/or alleged Creditor(s) have no lawful or verifiable
claim, and will constitute the Debt Collector(s) and/or alleged Creditor(s) waiver of any and all alleged claims
against Claimant, and agrees to forever hold harmless Claimant against any and all costs, fees, and/or charges
now and forever incurred involving the above referred alleged account or any and all other alleged accounts not
specifically enumerated herein. Debt Collector(s) and/or any alleged Creditor(s) may be liable for any and all
damages for any continued collection efforts, including any fees or obligations incurred by Claimant, failing the
completion of this Statement.

The use of any statutes, codes, rules, regulations, or court citations, within any document created by the
Claimant, at any time, is only to notice that which is applicable to Debt Collector and or alleged Creditor, and is
not intended, nor shall it be construed, to mean that alleged Debtor has conferred, submitted to, or entered into
any jurisdiction alluded to thereby.

Debt Collector is required to accurately and clearly input and attach all required disclosures to this "Debt
Collector Disclosure Statement" in writing by completing all of the following:

1. Name of Debt Collector: _________________________________________________________________

2. Address of Debt Collector: ________________________________________________________________

3. First Name of Debt Collector Agent/Representative completing this statement: ________________________

4. Last Name of Debt Collector Agent/Representative completing this statement: _________________________

5. Title of Debt Collector Agent/Representative completing this statement: ______________________________

6. Is Debt Collector Registered and/or Licensed to do business as Debt Collector and "collect a debt" within the
State in which they are attempting to collect the alleged debt? Circle YES or NO

7. If YES above, is Debt Collector bonded and/or insured within the same State in which they are attempting to
collect the alleged debt? Circle YES or NO

8. If YES above, what is the name and policy number of the insurance policy holder or underwriter?

Name:___________________________; Policy Number: ____________________________________

9. First Name of alleged Debtor: ____________________________________________________________

10. Last Name of alleged Debtor: ____________________________________________________________

11. Address of alleged Debtor: ________________________________________________________________

12. Alleged Account Number: ________________________________________________________________

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13. Amount of Alleged Debt owed: $___________________________________________________________

14. Date alleged debt became payable: ___________________________________________________

15. Have any insurance claims been made by any creditor or Debt Collector regarding Alleged Account? Circle
YES or NO

16. Is Debt Collector the "Original Creditor" of the Alleged Account? Circle YES or NO

17. If YES above, identify the source of funds and produce all records, reports, ledgers and memoranda that
prove beyond a reasonable doubt the "Original Creditor" was the source and origin of the funds.

18. If Debt Collector was NOT the "Original Creditor," provide the name and address of the "Original Creditor":

__________________________________________________________________________________________

19. Did Debt Collector purchase Alleged Account from "Original Creditor" listed in #17? Circle YES or NO

20. If YES above, provide date of purchase, and purchase amount of Alleged Account from Original Creditor:

Date: __________________; Amount: $________________________

21. Did Debt Collector purchase this alleged account from a previous debt Collector? Circle YES or NO

22. If YES above, provide date of purchase, and purchase amount of Alleged Account from previous debt

Collector:

Date: __________________; Amount: $________________________

23. Identify the name and address of the owner and/or business of the account that was debited when the Alleged
Account was created:

__________________________________________________________________________________________

24. Identify the account number that was debited when the Alleged Account was created: __________________

25. If Debt Collector purchased alleged account from "Original Creditor" or another debt collector what rights,
titles and
interest were transferred to Debt Collector resulting from the transaction? List them here:

__________________________________________________________________________________________

__________________________________________________________________________________________

26. What are the terms of assignment of the Alleged Account? Any records in support of the terms and
conditions of the assignment are to be returned with this statement.

27. Did Debt Collector provide alleged Debtor with verification of the alleged debt via sworn affidavit or a hand
signed invoice in accordance with the "Fair Debt Collection Practices Act"? Circle YES or NO

28. If YES above, provide the date verification was provided to the alleged Debtor: _______________________

29. Is Debt Collector current owner, assignee, holder, holder in due course, and/or entitlement holder of the
alleged debt? Circle YES or NO

30. If YES above, Debt Collector is to provide and return true, correct, complete and not misleading copies of
proofs and/or documentary or evidentiary records, sworn by wet-ink signature signed under the penalty of
perjury that the foregoing copies are true, correct, and not misleading with this "Debt Collector Disclosure
Statement".

31. Does the Debt Collector have and hold in their possession any verifiable original agreement, instrument or
contract between Debt Collector and alleged Debtor, that Debt Collector will verify under oath, affirmation or
deposition under the pains and penalties of perjury? Circle YES or NO

32. If YES above, If YES above, Debt Collector is to provide and return true, correct, complete and not
misleading copies of the original agreement, instrument or contract and verify under oath, affirmation,
deposition, under penalty of perjury that Debt Collector has first-hand, personal knowledge of the original
agreement, instrument or contract or state why Debt Collector cannot, or will not produce the same.

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33. Have any charge-offs been made by any creditor or debt collector regarding this alleged account? Circle
YES or NO

34. Have any tax deductions and/or tax-write offs been made by any creditor or debt collector regarding this
alleged account? Circle YES or NO

35. Have any judgments been obtained by any creditor or debt collector regarding this alleged account? Circle
YES or NO

36. Does the Debt Collector have any type or kind of verifiable claim, which complies with all of the provisions
set forth in the Fair Credit Reporting Act, codified at [15 USC 1681 et seq.] ? Circle YES or NO

37. If YES above, upon what basis does the Debt Collector rely upon for such claim? Explain:

__________________________________________________________________________________________

38. Did the Debt Collector, advise the alleged Debtor of the numerous rights which he maintains as accorded in
the Fair Debt Collections Practices Act codified at [15 USC 1692 et seq.]? Circle YES or NO

39. If YES above, Debt Collector will provide any documentary or evidentiary records in support of this claim
upon return on this statement.

40. Has Debt Collector reported any derogatory information regarding alleged Debtor to any Credit Reporting
Agency (CRA)? Circle YES or NO

41. If YES above, Debt Collector will provide any documentary or evidentiary records in support of the
procedures implemented, pursuant to the "Fair Credit Reporting Act", authorizing the filing of the same
derogatory information against alleged Debtor.

Declaration

The undersigned hereby declares, it is my personal knowledge and belief that the statements made herein are
true, correct, and not misleading under the pains and penalties of perjury under the laws of the United States of
America.

______________________ ___________________________________________
Date Printed Name of Signatory

______________________ ___________________________________________
Official Title of Signatory Authorized Signature for Debt Collector,
and/or Creditor, Undersigned.

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