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Disputed Account Settlement

This form disputes an account settlement between a creditor and debtor. The form provided here is simply a sample of what the actual form looks like.


Settlement Agreement by and between _____________________________

Of _________________________________ (Creditor)

And _________________________________

Of __________________________________ (Debtor).

Whereas, Creditor asserts to hold certain claim against Debtor

in the amount of ________________ dollars ($_________) arising from the below described transaction:

And whereas, Debtor disputes said claim, and denies said dept 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 _______________________ dollars ($__________) 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 _______________________, 20____.






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