Case Workflow — Step 2 of 2

USDCB Debt Resolution Program Application

Please complete and sign this application to continue your case review and next-stage debt resolution process. Your submission will be saved to your case record.

THE USDCB — UNITED STATES DEBT COLLECTION BUREAU

Collecting Department · 123 Your Street, Washington, DC 22009 · (123) 456-7890

Applicant Personal Information

First Name*

Middle Name

Last Name*

Date of Birth (mm/dd/yy)

SSN # (last 4 only)

Street Address

Apt / Unit

City

State

Zip Code

Phone Number

Cell Phone

Debt Account Information

1. Financial Institution

Institution Name

Time at Default (mm/yy)

Balance

Type of Loan

Account #

2. Financial Institution

Institution Name

Time at Default (mm/yy)

Balance

Type of Loan

Account #

3. Financial Institution

Institution Name

Time at Default (mm/yy)

Balance

Type of Loan

Account #

Length of Payments Designation

Select one payment plan. The agency will confirm your monthly rate within 48 hours.

Length	Interest/yr	Discount
12 months	0%	30%
24 months	0%	25%
36 months	4.2%	20%
48 months	4.2%	15%
60 months	4.2%	10%
72 months	4.2%	5%

**Interest rate based on 2024 mortgage rate and will change annually.

Applicant Signature

By typing your name below, you acknowledge and agree to the terms of the USDCB Debt Resolution Program.

Signature (type full name) *

Print Name / Last Name *

Date: September 26, 2026

Questions? customerservice@usdcb.gov · Phone: 202-000-5555 (M–F 9am–5pm)