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Debts Basics

Enquiry Form

For a free no obligation quotation, please complete the following form. A consultant will contact you within 48 hours to discuss our services. All information will be held in strict confidence.

Fields marked * are required

Your Personal Details

Email Address:

Title:

Surname:

Forenames(s):

Date of Birth:

(dd/mm/yyyy) *

Marital Status:

Number of Children living with you:

Address:

Living Arrangements:

If Homeowner:

Mortgage Amount
Estimated Current Value

Home Phone Number:

Work Phone Number:

Mobile Phone Number:

Most convenient time to contact you:

Do you live on your own?:

If Yes, is your partner or whoever you may live with aware of the difficulties?:

If they are not aware, who do you live with or who may answer the telephone?:

Can we leave messages with them?:

Can we discuss your situation fully with them?:

May we contact you at work?:

How long have you lived at your present address?

Do you have any children?

If Yes please give details of the child(ren):

Name of Child(ren)	DOB (dd/mm/yyyy)	Parents

Are any of the children who live with you in employment?:

Is there a CSA Assessment pending?:

Do you receive maintenance from an Ex-partner?:

If Yes, how much per month is received?:

Do you own a car?

If Yes, please give details of vehicle(s)

Vehicle 1:

Value
Make/Model
Age

Vehicle 2:

Value
Make/Model
Age

Your Employment Details
Job Description:
Company:
Date of Commencement:	dd/mm/yyyy
Gross Salary:

Partner's Employment Details
Job Description:
Company:
Date of Commencement:	dd/mm/yyyy
Gross Salary:

Your Income	(calendar monthly)
Your take home pay (including regular overtime):	^£
Partner's take home pay (including regular overtime):	^£
Other regular income (Child benefit/CSA/maintenance/pension/other benefits):	^£

	Your Expenditure	(calendar monthly)
	Mortgage:	^£
	or Rent:	^£
	Council Tax:	^£
	Water Rates:	^£
	Electricity:	^£
	Gas:	^£
	Telephone:	^£
	Telephone - (Mobile):	^£
	Car Expenses (include petrol, servicing, insurance & Road Tax):	^£
	Secured Car Loan / Car H.P.:	^£
	Public Transport:	^£
	Household Expenses:	^£
	Smoking:	^£
	Maintenance / CSA payments:	^£
	TV Licence:	^£
	TV / VCR Rental:	^£
	Endowment Policies / Pension:	^£
	Life Insurance:	^£
	Home Insurance:	^£
	Other Insurances (Medical , Health, ASU, Pet, Travel):	^£
Other (please state):		^£
Other (please state):		^£
Other (please state):		^£

Creditor Details
Name of Creditor	Total Amount Owing	Account No.
	^£
	^£
	^£
	^£
	^£
	^£
	^£
	^£
	^£
	^£

Reasons Why You Are In Debt
State what has caused your problems. How these problems have been incurred. The cost of these problems. Any losses which were uninsured. Any third party guarantees that have been called upon. Credit Card debts. Legal Actions lost and why. Any loss of income..

How Did You Hear Of Us?
Existing client:
Professional contact:
Internet search:
Other:

Additional Comments
If you have any comments you'd like to make or questions you'd like to ask, please enter them here.

	I authorise you to pass my information to third parties to enable the debt management service to be provided.
Once you have completed the form, press Send to submit it to us so that we can conduct a Personal Credit Review. Alternatively, press Reset to clear everything.