Online Assistance Request

Request assistance for help with your debt

If you are willing to provide us with some more detailed information concerning yourself and your debt problem (including contact details), which will enable us to deal with your problem more quickly, please complete the form below.

| Brief Information Form* | Detailed Information Form |

Detailed Information Form

Contact Details
Title	Please Select ... Mr Ms. Mrs Miss Dr. Prof.
Full Name
Address
Country
Daytime telephone number
Evening Telephone Number
Mobile telephone number
Email Address
Personal Details
Date of birth (dd-mm-yyyy)	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985
Marital status	Single Engaged Married Divorced/Widowed
Number of dependents	00 01 02 03 04 05 06 07 08 09 10 11 12
Name of partner
Age of partner	years
Financial Details
Tenant or homeowner (please note we can assist tenants and homeowners)	Tenant Homeowner
Sole or joint owner	Sole Joint N/A
Value of property	£
Outstanding mortgage	£
Amount of other debt secured on house	£
Hire purchase / finance agreements Please provide details of any items subject to hire purchase or other finance agreements, including the amount owed and who is responsible for the debt.
Other debts not secured on your house Please indicate the total amount owed by you and your spouse respectively. These would include personal loans, credit cards, store cards, bank overdrafts, amounts owed to catalogue companies, utility & council tax arrears, trade creditors, amounts owed to family members and any other debts
Total amount owed:	£
You:	£
Your spouse:	£
Employment / Income
	You	Spouse
Occupation
Employed or self employed	Employed Self-employed	Employed Self-employed
Net / "take home" pay per month	£	£
Benefits / tax credits received	£	£
What is your joint monthly surplus income, before making any payments concerning those debts not secured on your house?	£
Other Information Please provide any other relevant information - such as further details of problem, details of any significant assets etc.

 

Call us on 0800 88 18 274 to find out how we can help at the Debt Help Line