Email or Text?

Please fill out the following form to communicate with The Allen Daniel Associates, Inc. through either email or text messaging.

This is an attempt to collect a debt and any information obtained will be used for that purpose.

Who do you owe the money to?

Account/Reference Number

I authorize The Allen Daniel Associates, Inc. to contact me by:


 FOR “CONSUMERS” ONLY. I am not providing The Allen Daniel Associates, Inc. with an e-mail address provided to me by my employer or related in any manner to my workplace or place of employment. I am acknowledging that I do not have a reasonable expectation of privacy in an e-mail address associated in any way with my employment. I am also acknowledging that I am aware of who else in my household may intercept Electronic Communications (for example, family members and roommates) and have taken all precautions to eliminate others from accessing my Electronic Communications.


Text on

Do we have your consent to text your cell phone?  Yes No

Do we have your consent to call your cell phone?  Yes No

For Verification purposes please enter the following:

Date of Birth:

Last 4 digits of SSN:

Electronic Signature

Please enter validation code: captcha