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Assessment Form
Assessment Form
Approximately how much debt do you have (excluding mortgage)?
Please Select
£2,500.00
£5,000.00
£7,500.00
£10,000.00
£12,500.00
£15,000.00
£17,500.00
£20,000.00
£22,500.00
£25,000.00
£27,500.00
£30,000.00
£32,500.00
£35,000.00
£37,500.00
£40,000.00
£42,500.00
£45,000.00
£47,500.00
£50,000.00
£52,500.00
£55,000.00
£57,500.00
£60,000.00
£62,500.00
£65,000.00
£67,500.00
£70,000.00
£72,500.00
£75,000.00
£77,500.00
£80,000.00
£82,500.00
£85,000.00
£87,500.00
£90,000.00
£92,500.00
£95,000.00
£97,500.00
£100,000.00
How many creditors do you have?
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Do you own your own home?
Please Select
Yes
No
Your Full Name:
Your house number and Postcode:
Telephone Number:
Mobile Number:
Email Address:
Personal Information
Current Employment Status:
Please Select
Full-Time Employed
Part-Time Employed
Self-Employed
Company Director
Unemployed
Are you struggling to make your repayments?
Please Select
Yes
No
How much do you feel you can afford toward your debts?
Please Select
£50-£100 per month
£100-£150 per month
£150-£200 per month
£200-£250 per month
£250-£300 per month
£300-£350 per month
£350-£400 per month
£400-£450 per month
£450-£500 per month
£500+ per month
Please try to be realsitic with your estimate.
Brief Debt History:
Requested Contact Day/Time:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
@
10
11
12
13
14
15
16
17
18
19
20
21
22
:
00
15
30
45
I confirm I am over 18 years old and have read and understand
privacy policy
.