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Your Details
Title:
Please select:
Mr
Mrs
Miss
Ms
First Name:
Surname:
Telephone:
Mobile:
House Number:
Street:
Town:
County:
Postcode:
Email Address:
How did you hear about us?:
Please select:
Google
Phone Call
Advert
E-mail
Newspaper
Friend
Your Situation
Unsecured Total Debt:
Please select:
£1000 - £2000
£2000 - £3000
£4000 - £5000
£5000 - £10000
£10000 - £15000
£15000 - £20000
£20000 - £25000
£25000 - £50000
£50000 - £75000
£75000 - £100000
£100000 +
Monthly Net Income £:
Residential Status:
Please select:
Homeowner - with mortgage
Homeowner - no mortgage
Private Tenant
Living with Parent(s)
Other
Employed Status:
Please select:
Employed
Self Employed
Unemployed
Homemaker
Student
Retired
Other
Number of Creditors unsecure debt is owed to:
Please select:
0
1
2
3
4
5
6
7
8
9
10
Over 10
Name of Creditors: 1)
2)
3)
How much do you pay per month towards your unsecured debt? £:
After you get paid each month & you have paid only your rent/mortgage, how much money do you have left?
(Before paying your utilities, creditors & general living costs)
:
Please select:
£80 - £100
£100 - £150
£150 - £200
£200 - £250
£250 - £300
£300 - £350
£350 - £400
£400 -£450
£450 - £500
£500 - £600
£600 - £700
£700 - £800
£800 - £900
£900 - £1000
£1000 plus
After you pay all your creditors at the end of the month do you find you are struggling with your repayments?:
Please select:
Yes
No
Residential Status (homeowner with mortgage)
Residential Status (homeowner with no mortgage)
Mortgage Balance (approx.) £:
Monthly Mortgage Payment £:
Value of Property (approx.) £:
Do you have a secured loan?:
Please select:
Yes
No
If Yes, please provide details:
Secured Loan Balance £:
Secured Loan Payments £:
Residential Status (private tenant)
Rent £:
Residential Status (living with parents)
Board, including meals £:
Residential Status (other)
Details:
Would you like to tell us more now?
Please select:
Yes
No
Council Tax (per month) £:
Gas (per month) £:
Water (per month) £:
Electric (per month) £:
Housekeeping (per month) £:
Clothing (per month) £:
Transport (per month) £:
Social Expenses (per month) £:
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