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Contact Information
Name:
Email:
Phone Number:
Best Time To Call:
Any Time
Morning
9.00 - 10.00 am
10.00 - 11.00 am
11.00 - 12.00 am
Afternoon
12.00 - 1.00 pm
1.00 - 2.00 pm
2.00 - 3.00 pm
3.00 - 4.00 pm
4.00 - 5.00 pm
Evening
5.00 - 6.00 pm
6.00 - 7.00 pm
7.00 - 8.00 pm
Personal Information
Marital Status:
Single
Married
Divorced
Living with partner
Separated
Widowed
Do have any children
NO
YES
Number of Children Living with you:
maintenance / csa payments:
nursery / childcare:
Type of Residency:
Homeowner
Tenant
Lodger
Living with parents
Other
Your Monthly Income
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 Monthly Expenditure
Council Tax:
Water Rates:
Electricty:
Gas:
Telephone:
Mobile Telephone:
Public Transport:
Household Expenses (Food, Clothes, Toiletries):
Smoking:
TV Licence:
TV / VCR Rental:
Do own any transport (Car/Motorbike)
NO
YES
Car Expenses (include petrol, servicing, insurance & road tax):
Car Finance (Loan, Lease, HP):
endowment policies:
life insurance:
home insurance:
other insurances (medical , health, asu, pet, travel):
pension contributions:
Rent:
Do you have a mortgage
NO
YES
how much is outstanding on your mortgage?:
what type of mortgage do you have? (i.e. repayment, endowment, pension mortgage):
when did you take your mortgage out (please try to give a month and a year):
who is your lender?:
how much is you home worth, approximately?:
how long is left on your mortgage? (in years):
does your mortgage have any redemption penalties?:
Don't Know
Yes
No
Second mortgage:
Your Creditors Details
Creditors Name
Amount Owed
Monthy Payments
Additional Comments
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