Debt questionnaire We can provide you with a free initial assessment of your financial position and how best to proceed. All you need to do is complete this questionnaire and we will contact you once we have considered your circumstances.
Title	-- Please choose -- Mr Mrs Miss Ms Professor Dr Other
Full Name*
Address 1*
Address 2*
Address 3
Post Code*
Telephone numbers:
Home*
Work
Mobile
Please provide us with a list of all of your creditors:
Name of original creditor - Account No - Estimated Balance 1. 2. 3.
Do you own your own house? - if Yes what is it worth and what is the total outstanding mortgage?	House is worth: £ Total outstanding mortgages are: £
Do you own your own car? - if Yes make and value: - is it subject to a Hire Purchase agreement?	Car make: Car value: £ Outstanding balance: £
Do you own any policies? – if Yes do they have a surrender value?
What surplus income each month can you afford to pay to your creditors once you have paid all your household bills and expenses?
* required fields - if left blank, the form will not submit correctly
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