To fill out this letter, clearly write your name and address at the top. Include the date and the collection agency's name and address.Below is a sample, fillintheblank letter that you can use as a guide for disputing a debt with a collector. How to use this sample letter: 1. Read the background below. 2. Want to settle your debt? I am writing in regards to the above-referenced debt to inform you that I am disputing this debt. A debt settlement letter is all you need to negotiate debts with your creditors. It asks you to pay a certain settlement amount to the collection agency. COMMERCIAL DIVISION SAMPLE CHOICE OF FORUM CLAUSES. Purpose.