Make an Offer

Please complete the form below to make an offer on your account to Lyons, Doughty & Veldhuis P.C./P.A.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Work or Personal Email(Required)

Would you like a response to this inquiry via email?(Required)

May we email you about your account in the future (even if this is a work email address)?(Required)

Home Phone (Land Line)

Cell Phone

Work Phone

You may call me at work if necessary

You may call my cell phone if necessary

If you select yes, you are authorizing us to call your cell phone manually or by electronic dialer and to leave messages for you on any telephone.

Place of Employment

Your relationship with the accountholder

If you are not the accountholder, enter the name of the accountholder

Date of Birth(Required)

Last four digits of social security number(Required)

Offer Type

Date you can make/start payments(Required)

Please submit the details of your offer

Please type 'yes' if you have read everything on this page(Required)

This firm is a debt collector.

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