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1. What is your name?

2. What is your address?

3. Who is the creditor or lender you are addressing?

4. What is the address of the creditor or lender?

5. What type of debt or loan are you requesting assistance with? (credit card debt/mortgage/auto loan/student loan/other)

6. What is the reason for your financial difficulties?

7. Please explain the hardship in 1-2 sentences.

8. What specific assistance or relief are you requesting? (Reduction or settlement of the debt/a payment plan/a forbearance agreement/other)

9. What is today's date?