DEBT COLLECTOR DISCLOSURE STATEMENT

Notice to Agent is Notice to Principal ~ Notice to Principal is Notice to Agent

NOTICE: THIS DOCUMENT IS NOT INTENDED TO THREATEN, HARASS, HINDER OR

OBSTRUCT ANY LAWFUL OPERATIONS. IT IS FOR THE PURPOSES OF OBTAINING
LAWFUL REMEDY AS IS PROVIDED BY LAW.

September 2, 2010

Respondent: Donald Duck

123 Main St
Anaheim, California 92801

Debt Collector: Via Certified Mail Receipt

LIE, CHEATUM AND BEATUM
2151 SALVIO STREET SUITE W
CONCORD, CA 94520

RE: ACCOUNT #123455 / ORIGINAL CREDITOR – BANK OF BS

To whom it may concern:

This statement and the answers contained herein may be used by Respondent, if necessary, in any court
of competent jurisdiction.

Notice: This Debt Collector Disclosure Statement must be completed in accordance with the Fair Debt
Collection Practices Act, 15 USC §1692g, Title VIII Debt Collection Practices, § 809 of the Federal
Trade Commission, applicable portions of Truth in Lending (Regulation Z), 12 CFR 226, and demands
as cited above Disputed Debt. Debt Collector must make all required disclosures clearly and
conspicuously in writing re the following:

1.Name / Address of Debt Collector:

___________________________________________________________________________________

2. Name / Address of Alleged Debtor:

___________________________________________________________________________________

3. Alleged Account Number: _______________________________________________________

4. Alleged debt owed : $ __________________________________________________

5. Date alleged debt became payable: __________________________________________

6. Name / Address of alleged Original Creditor, if different from Debt Collector?

___________________________________________________________________________________

7. Re this alleged account, if Debt Collector is different from alleged Original Creditor, does Debt
Collector have a bona fide affidavit of assignment to enter into alleged original contract between
alleged Original Creditor and alleged Debtor? YES NO
8. Did Debt Collector purchase this alleged account from the alleged Original Creditor? YES NO
N/A (Not Applicable)

9. If applicable, date of purchase of this alleged account from alleged Original Creditor, and purchase
amount: Date:__________________________ Amount: $__________________________________

10.Did Debt Collector purchase this alleged account from a previous debt collector? YES NO
N/A
11. If applicable, date of purchase of this alleged account from previous debt collector, and purchase
amount: Date:_____________________ Amount: $_________________________________

12. Regarding this alleged account, Debt Collector is currently the:

Owner; (b) Assignee; (c) Other – explain:_________________________________________________

13. Has Debt Collector provided alleged Debtor with the requisite verification of the alleged debt as
required by the Fair Debt Collection Practices Act? YES NO
14. Date said verification cited above in # 13 was provided alleged Debtor: ______________________
15. Was said verification cited above in #13 in the form of a sworn or affirmed oath, affidavit, or
deposition? YES NO
16. Have any charge-offs been made by any creditor or debt collector regarding this alleged account?
YES NO
17. Have any insurance claims been made by any creditor or debt collector regarding this alleged
account? YES NO
18. Have any tax write-offs been made by any creditor or debt collector regarding this alleged account?
YES NO
19. Have any tax deductions been made by any creditor or debt collector regarding this alleged
account? YES NO
20. Has the Statute of Limitations expired on this debt? YES NO
Debt Collector’s failure, both intentional and otherwise, to complete/answer points “1” through “20”
above and return this Debt Collector Disclosure Statement, as well as provide Respondent with the
requisite verification validating the hereinabove - referenced alleged debt, constitutes Debt Collector’s
tacit agreement that Debt Collector has no verifiable, lawful, bona fide claim regarding the
hereinabove-referenced alleged account, and that Debt Collector tacitly agrees that Debt Collector
waives all claims against Respondent and indemnifies and holds Respondent harmless against any and
all costs and fees heretofore and hereafter incurred and related regarding any and all collection attempts
involving the hereinabove-referenced alleged account.
Declaration: The Undersigned hereby declares under penalty of perjury of the laws of this State that the
statements made in this Debt Collector Disclosure Statement are true and correct in accordance with
the Undersigned’s best firsthand knowledge and belief.

____________________________________ ____________________________________
Date Printed name of Signatory
____________________________________ ____________________________________
Official Title of Signatory / Authorized Signature for Debt Collector /Must be notarized

Debt Collector must timely complete and return this Debt Collector Disclosure Statement, along with
all required documents referenced in said Debt Collector Disclosure Statement. Debt Collector’s claim
will not be considered if any portion of this Debt Collector Disclosure Statement is not completed and
timely returned with all required documents, which specifically includes the requisite verification,
made in accordance with law and codified in the Fair Debt Collection Practices Act at 15 USC §1692
et seq., and which states in relevant part: “A debt collector may not use any false, deceptive, or
misleading representation or means in connection with the collection of any debt,” which includes “the
false representation of the character, or legal status of any debt,” and “the threat to take any action that
cannot legally be taken,” all of which are violations of law. You should also be aware that sending
unsubstantiated demands for payment through the United States Mail System might constitute mail
fraud under federal and state law. If Debt Collector does not respond as required by law, Debt
Collector’s claim will not be considered and Debt Collector may be liable for damages for any
continued collection efforts, as well as any other injury sustained by Respondent. Failure to complete
and return this Debt Collector Disclosure Statement shall acknowledge the debt uncollectable
and deleted with all major credit bureaus. Please allow thirty (30) days for processing after
Respondent’s receipt of Debt Collector’s response.
Debt Collector’s failure to respond as requested in full and completely shall also prohibit any further
collection activities, including transfer or selling of this debt to successor assignees.

Sincerely,

Your Name Here

A volunteer, stranger, or intermeddler is "one who thrusts himself into a situation on his own initiative, and not one who
becomes a party to a transaction upon the urgent petition of a person who is vitally interested, and whose rights would be
sacrificed did he not respond to the importunate appeal." Laffranchini, 39 Nev. 48, 153 P. at 252. Parties may be
considered volunteers if, in making a payment, they have no interest of their own to protect, they act without any
obligation, legal or moral, and they act without being requested to do so by the person liable on the original
obligation. Henningsen v. United States Fidelity Guar. Co., 208 U.S. 404, 411 (1908); Smith v. State Sav. & Loan
Ass'n, 175 Cal. App. 3d 1092, 1098, 223 Cal. Rptr. 298, 301 (1986); Norfolk & Dedham Fire Ins. Co. v. Aetna Casualty &
Surety Co., 132 Vt. 341, 344, 318 A.2d 659, 661 (1974).