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Section 1: Your Information
Before we can give you email advice we need to keep accurate records to comply with legislation. Please would you fill out the following details which should take no longer than
5 minutes to complete:-
Date of Birth
National Insurance Number (if known)
Section 2: Debt Enquiry Area
Type of debt (tick all applicable):
Priority (rent, council tax, secured loan, income tax, electricty, gas, water)
Non-priority (non-secured bank loans, credit cards, store cards, etc.)
If 'other', please give details below.
Total debt (£):
Total household income (£):
Household income frequency:
Number of people in your household
Ages of children
Brief details of enquiry:
Section 3: Data Protection Act 1998
The law says that we must get your permission to keep some details about you. Everything you tell us will be treated in absolute confidence and all records are stored securely.
Section 4: Conflict of interest
If you are in dispute, we need to know the name of the person. This is because we can’t advise both people, and we also need to make sure our advice and information is fair and impartial.
If applicable, the name of the person I am in dispute with is:
Section 5: Profile
To help improve our services, we need to know whether all groups in the community are being served. We are asking you the questions below so that we can check this. Your answers will only be used anonymously to build up a statistical picture of our clients.
Ethnic Origin: *
Number in household:
Section 6: Submit