Debt Contact Us Form

Title

First and Last Name (required)

Address including postcode

Gender (required)

Date of Birth (required)

Mobile telephone number: (required)

Email address: (required)

Ethnicity (We need your explicit consent to record your ethnicity. If you do NOT agree to this please type ’Prefer not to say’.) (required)

Disability/ Health Problems (We need your explicit consent to record your Disability. If you do NOT agree to this please type ’Prefer not to say’.) (required)

House (required)

Household Type (required)

Employment

What benefits do you receive? (required)

Number of children and their ages (if applicable): (required)

Do you have any arrears? (mortgage, benefits overpayment, store/credit cards) (required)

If yes, please list them:

What is the total debt?

Please describe your issue, if possible please give relevant dates.

Do you have access to the internet?

Are you confident using the internet for research and filling out forms?