Credit Report / Identity Theft Evaluation Form

Prospective Client Intake Form

Date:   
*Name:   
Street Address:   
City:   
State:   
Zip:   
Home Phone:   
Work Phone:   
Cell Phone:   
*Email Address:   
Referred by:   
 
1. Do you have recent copies of your credit reports from each of the three credit bureaus (dated within the last month)?:
 
2. Are there inaccurate accounts on your credit report?:
 
3. If yes, what accounts are inaccurate and why are they inaccurate? (need account name):
Account #1:

Account #2:

Account #3:

 
4. Have you contact any of the credit bureaus to dispute the incorrect accounts?:
 
5. If yes, did you contact:
Experian?
Equifax?
Trans Union?
 
6. If yes, how did you contact the credit bureaus?:
By telephone?
By email?
By letter?
 
7. Do you have a copy of your email or letter to the credit bureau?:
 
8. If you contacted the credit bureaus by letter, did you send the letter by certified mail?:
 
9. Have you received any responses from the credit bureaus regarding your dispute of the incorrect items on your credit report?:
 
10. If yes, which credit bureaus responded to your dispute?:
 
11. What was the response of the credit bureaus?:

 
12. Did you contact any of the companies that were listed incorrectly on your credit report?:
 
13. If yes, how did you contact the companies regarding your credit report?:
By telephone?
By email?
By letter?
 
14. Do you have a copy of your email or letter to the companies?:
 
15. If you contacted the companies by letter, did you send the letter by certified mail?:
 
16. Have you received any responses from the companies regarding your dispute of the incorrect items on your credit report?:
 
17. If yes, which companies responded to your dispute?:
 
18. What was the response of the companies?:

 
19. Have you been denied credit or employment due to the errors on your credit report?:
 
20. If yes, do you have any written documentation of the denial of credit or employment?:
 
21. Have you incurred any expenses due to this problem (loss time at work, postate, etc.)?:
 
22. Have you sought advice and/or assistance of other professionals to help you deal with the problems with your credit report?:
 
23. If yes, who have you consulted?:
 
24. Are you a possible victim of identity theft?:
 

Fill Out These Questions for Identity Theft Victims
25. If you are a victim of identity theft, how did you find out that you were a victim?:

 
26. Do you know the person who stole your identity?:
 
27. If yes, what is the person's relationship to you?:
 
28. Have you filed a police report?:
 
If yes, where?:
 
If no, why not?:
 
29. Have you been contacted by the companies where the fraudulent accounts were opened?:
 
30. If yes, have they contacted you by:
By telephone?
By letter?
 
31. If you've been contacted by letter, do you still have the letters?:
 
32. Have you been sued over any of the fraudulent accounts?:
 

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