Please complete the details below before submitting your application.
We will contact you to discuss all details before proceeding.
Contact information
Personal details
Property details
Assets
Creditor information
Income & expenditure
History
YOUR CONTACT INFORMATION
Please note that your "ENTER" button will submit your details
Please use your "TAB" key to move to the next line
First Name Last Name Middle Initial Title Mr Mrs Miss Ms Address Postcode Work Phone Home Phone E-mail Back to contents
First Name
Last Name
Middle Initial
Title
Mr Mrs Miss Ms
Address
Postcode
Work Phone
Home Phone
E-mail
Back to contents
PERSONAL DETAILS
Marital Status Married Single Divorced Separated Widowed Other Partners Name Maiden Name Date of Birth Back to contents
Marital Status
Married Single Divorced Separated Widowed Other
Partners Name
Maiden Name
Date of Birth
PROPERTY DETAILS
Is your property
Rented
If owned state value
£
If jointly owned - name other co-owners
If mortgaged state balance
Any arrears
ASSETS
List asset and value
PLEASE PROVIDE ALL UNSECURED CREDITOR INFORMATION
Company Name 1 Address Postcode Account Number Balance Company Name 2 Address Postcode Account Number Balance Company Name 3 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 4 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 5 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 6 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 7 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 8 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 9 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 10 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 11 Address Postcode Account Number Balance If you have no more creditors click here to go to the next section Company Name 12 Address Postcode Account Number Balance Back to contents
Company Name 1
Account Number
Balance
Company Name 2
Company Name 3
If you have no more creditors click here to go to the next section
Company Name 4
Company Name 5
Company Name 6
Company Name 7
Company Name 8
Company Name 9
Company Name 10
Company Name 11
Company Name 12
INCOME & EXPENDITURE
INCOME
Salary/Wage Applicant
Salary/Wage Partner
Pension
Child Benefit
DLA/DWA/WFTC
Income Support
Maintenance
Other
EXPENDITURE
Mortgage/Rent
2nd Mortgage
Water Charges
Council Tax
Gas
Electricity
Insurance-Contents/Building
Food/Housekeeping
Telephone
TV Rental/Licence
Car Tax/Insurance/Maintenance
Car Fuel
Clothing
Medical Prescriptions
Childrens Activities/Childcare
School Meals
HISTORY
Please give details as to why you find yourself in your current financial situation
Other information that may be relevant to your application as well as recent legal action
Due to the Data Protection Act 1998 , we will require your signed authority before we can proceed with your application.
Please go to the AUTHORITY form then print, sign and either post,
fax to 0870-1634656 or scan and email to mail@direct-debt-management.co.uk
Contents Contact Information Personal Details Property Details
Assets Creditor Information Income & Expenditure History
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