Full Name

Email Address

Phone Number

Date of Birth

Residential Address

SSN (Optional)

What is your current credit score range?
Select Current Credit Score Range300–499500–579580–669670–739740+

What are your credit goals?
Select Credit GoalsBuy a homeBuy a carLower interest ratesImprove scoreRemove negative itemsOther

What issues are you experiencing?
Select issueLate paymentsCollectionsCharge offsRepossessionsBankruptcyIdentity theftMedical billsStudent loansOther

Do you already have a recent credit report (within the last 30 days)?
YesNo

Do you already know which items you want to dispute?
YesNo

Upload ID

Upload Proof of Address

Upload Additional Documents (optional)

Would you like to share any additional financial background?
YesNo

Best time to reach you
Select preferred timeMorning (8am – 11am)Midday (11am – 2pm)Afternoon (2pm – 5pm)Evening (5pm – 8pm)

Preferred communication method
Phone CallEmailText Message

Additional notes or information you would like to share

I authorize Regency Wealth Solutions to assist with credit repair services.

I understand results vary and no specific outcome is guaranteed.