Letter of Disputed Account Settlement : Please fill out the following form. Please print your completed form if you would like to have a copy for your records.
Settlement Agreement by and between (name of the creditor) of (address of the Creditor) and (Name of the debtor) of (address of the Debtor) :
Whereas, Creditor asserts to hold a certain claim against Debtor in the amount of $___________ arising from the below described transaction :
Description of transaction
And whereas, Debtor disputes said claim, and denies said debt is due.
And whereas, the parties desire to resolve and forever settle and adjust said claim.
Now, therefore, Debtor agrees to pay to Creditor and Creditor agrees to accept from Debtor simultaneous herewith, the sum of$___________ in full payment, settlement, satisfaction, discharge and release of said claim and in release of any further claims thereto. Creditor acknowledges that there shall be no adverse report filed against Debtor with any credit bureau.
This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns and personal representatives.
Signed this day of (date with year) :
Letters for Credit and Collection Index
Letter of Disputed Account Settlement
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