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(Date of Letter)

Credit Bureau Attn: Reporting Agent (Street Address) (City, State and Zip Code) RE: Notice of Claim

Dear Reporting Agent: Please be advised that the undersigned wishes to assert a claim for (amount of claim) for sums due and owing to the undersigned from (name of debtor). The debt incurred in this matter to the undersigned by the aforementioned party was a result of $ (description of the basis of the claim). Attached please find documents which substantiate this claim, including the identity of the debtor, the address of the debtor, the location of the debtor, the amount of the claim, the reason for the claim and any payments made against the original amount due. Should your office need any additional verification in regard to the foregoing, please do not hesitate to contact the undersigned. Thank you. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number)

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