Creditor Harassment Incident Report
Use this form to document alleged harassment by a creditor or debt collector, including what happened, when it happened, who was involved, and any evidence you have.
Reporter Information
Full Name
*
First Name
Last Name
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Relationship to the Account
*
Debtor/Borrower
Spouse or Family Member
Authorized Representative
Witness
Other
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
Date
Incident Time
Hour Minutes
AM
PM
AM/PM Option
Incident Location or Channel
*
Phone call
Voicemail
Text message
Email
Letter
In person
Social media
Other
Creditor or Collection Agency Name
*
Contact Method Used by the Creditor
*
Phone call
Voicemail
Text message
Email
Letter
In person
Social media
Other
Harassment Description
Describe what happened
*
How often has the contact occurred?
*
Please Select
Once
2-3 times
Weekly
Daily
Multiple times per day
Other
Names, titles, or employee/badge references of people involved
What types of threats, abusive language, or deceptive statements were made?
Threats of legal action
Threats of arrest or detention
Threats of wage garnishment
Threats to contact others about the debt
Profanity or insults
False claim of being a government official
False claim of court action
Misrepresented debt amount or status
Other deceptive statements
Was the contact directed to a workplace, family member, or third party?
*
Workplace
Family member
Third party
No
Other
Evidence and Witnesses
Witness Name
First Name
Middle Name
Last Name
Witness Contact Information
Available Evidence
Call logs
Voicemails
Screenshots
Letters
Emails
Recordings
Other
Upload Evidence Attachments
Upload a File
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