Request a Payment Plan / Settlement

To apply for a payment plan or make a settlement offer, please complete this form and press the send button. Your answers to these questions will help our client better understand your ability to pay. Be sure to include a daytime phone number where we can reach you regarding your payment plan request. fields are marked with an asterisk(*).

Personal Information

Name:*

Please let us know your name.

Our File Number:

Invalid Input

Date of Birth:*

Invalid Input

Mailing Address:*

Invalid Input

City:*

Invalid Input

State:*

Invalid Input

Zip:*

Invalid Input

Street Address:

Invalid Input

Phone:*

Email:*

Please let us know your email address.

Employer Information

Are you employed?*

Yes No Other Invalid Input

If you chose Other, please explain:

Invalid Input

Employer Name:

Please let us know your name.

Employer Address:

Invalid Input

Employer City:

Invalid Input

Employer State:

Invalid Input

Employer Zip:

Invalid Input

Can you receive calls at work?

YesNo Invalid Input

Employer Phone:

Other Information

Are your wages being attached or garnished?*

Yes No Invalid Input

If yes, is the wage attachment for child support?

YesNo Invalid Input

How old is the youngest child(ren)?

Invalid Input

Are you in the military?*

YesNo Invalid Input

Is your spouse in the military?*

YesNo Invalid Input

Motor Vehicle Information

Do you own a Motor Vehicle in your name in the state of Delaware?*

YesNo Invalid Input

Vehicle Year:

Vehicle Make:

Vehicle Model:

Payment Information

Are you in a position to pay your settlement account in full within 30 days?*

YesNo Invalid Input

If you answered No to a full payment, what amount would you propose?

Invalid Input

We understand that you want to pay your bills. We also understand that one size does not fit all. We offer you some choices to arrange your payments.*

MonthlyTwice a monthWeekly Invalid Input

Please choose a day of the month between 1 and 28 that is most convenient for you to make your Payment.*

Invalid Input

How much do you plan to pay each plan date? *

Invalid Input

If you need more room to complete an answer, or would like to add additional information about your Financial situation, please enter below.

Invalid Input

I certify that foregoing statements are true. I give permission to Patrick Scanlon, P.A. to verify these statements. The electronic signature appearing below is mine.

Signature (type full name):*

Invalid Input

Date:*

Invalid Input

Law Offices of

Patrick Scanlon, P.A.