Debt Pack

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Please read the attached documents and tick below to agree you have done this:

Useful Information

Additional Content

How We Will Work With You

Complaints

This document includes:

How we look after the information you give us
Options for dealing with debt
What happens if I can’t pay my debts
Coping with the rising cost of living

Once you have completed your debt pack please include:

proof of income; and
2 months of bank statements

You will be able to do this at the end of the form.

*We are aware that some information is duplicated but this is due to some of the forms being required by our partner, Money and Pensions Services. Please complete all the information, even if you have already provided it in a previous section.

I have proof read *

PLEASE READ THE ABOVE 3 DOCUMENTS BEFORE CONTINUING.

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We offer the following appointments (please select your preference): *

Face to Face
Telephone

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How we use your information

As part of the advice session today we will ask you for some details about yourself and the issue you are looking for help with. We will use this information to provide you with advice, as well as to improve our service and inform our campaigns. If you want more detail about your rights and how we use your information, you can read our privacy notice on our website.

citizensadvice.org.uk/myinformation
https://citizensadviceeastsuffolk.org.uk/privacy-policy

Personal Details

Title

Client Name: *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Town of Birth: *

Mobile *

National Insurance Number *

Home Tel

Work Tel

Date of Birth *

Gender

Status: *

Single
Married
Co-habiting
Separated
Divorced
Widowed
Civil Partners

About your household (all occupants)

Do you have a partner or spouse?

Spouse/Partner’s Name: *

Date of Birth (DD/MM/YYYY): *

Spouse/Partner’s National Insurance Number: *

Does anybody else live with you? *

Names and dates of birth of any other people who live with you. Please state whether they are dependent (i.e. you receive Child Benefit for them).

Person 1

Name

First

Last

Relationship

Date of Birth (DD/MM/YYYY)

Dependent

Savings / Investments (Please state amount): *

Do you receive benefits

Your Benefits (Tick all that apply to you and your partner) *

Income Support
Universal Credit
Child Benefit
Housing Benefit
PIP / DLA Mobility
Job Seekers Allowance
Working Tax Credit
State Pension
Council Tax Benefit
PIP / DLA Care
Employment Support Allowance
Child Tax Credit
Pension Credit

Your Housing *

Owner Occupier
Private rented
Live with family / friends
Local Authority (Council)
Housing Association
Other

Do you own a property? *

Property/s

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Approximate value of all property *

Outstanding mortgage amount

Your Employment: *

Full-time
Part-time
Unemployed
Retired / Student

Your Partners Employment:

Full-time
Part-time
Unemployed

Part Time Hours

Contact preferences

From time to time, we may need to contact you about your enquiry outside of an appointment. Please indicate your preferred contact methods.

I prefer to be contacted about my advice query by (please select all that apply): *

Email
Mobile
Address
Home Telephone
Work Telephone

Please do not use the following contact:

Email
Mobile
Address
Home Telephone
Work Telephone

Contact for research and feedback

We want to get feedback on the advice we provide. We will use this information to improve our service and inform our campaigns in a way that doesn’t identify you. If you want more detail about your rights and how we use your information you can read our privacy notice on our website.

I agree to Citizens Advice selecting me for feedback using my information and contacting me.

I agree to Citizens Advice selecting me for feedback using my information and contacting me.

Please do not contact me for feedback using:

Email
Mobile
Address
Home Telephone
Work Telephone

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About You

To help us improve our services, we use these questions to check whether we are helping all groups in the community. Your answers will be confidential – they will only be used anonymously to build up a picture of our clients. The information also helps us, as an independent charity, to bid for the funding we need to continue to provide our services.

Ethnicity, Nationality and Language:

White

British
Irish
Scottish
Romany/Gypsy/Traveller
Other

Asian or Asian British

Indian
Pakistani
Bangladeshi
Other

Mixed

White & Black Caribbean
White & Black African
White & Asian
White & Other

Black or Black British

Caribbean
African
Other

Other

Chinese
Any other
Prefer not to say

Nationality:

Preferred language:

Disability / Health Problems (select all that apply):

Not disabled
Long-term health issues
Prefer not to say
Mental health problem
Physical impairment (non-sensory)
Visual impairment
Hard of hearing
Deaf
Other physical impairment
Learning difficulty
Cognitive impairment
Other

Household Types:

Single person
Single person with dependent children
Single person with non-dependent
Couple
Couple with dependent children
Couple with non-dependent
Prefer not to say

Housing Type:

Owned (no mortgage)
Buying (mortgage)
Shared ownership
Private tenant
Rent-free – with job
Relatives / friends house
Prison
Homeless
Council/Housing Association
Other

Employment Status:

Employed 30 hours or more
Employed under 30 hours
Unemployed – disabled
Unemployed – sickness
Unemployed
Volunteer
Retired
Student
Carer – elderly/disabled
Carer - children
Looking after home – no dependents
Government employment scheme
Other
Prefer not to say

Marital Status:

Single
Married/Cohabiting/Civil
Married but separated
Divorced
Widowed
Prefer not to say

If you were referred, who suggested that you come here? (e.g. Job Centre, Doctor, Council):

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Income and Expenses Sheet

*Net = After tax/insurance *Gross = Before tax/insurance

Please note: To convert weekly amounts into monthly, multiply by 52 and then divide by 12

Do You Have A Partner?

Income

How Often

Weekly
Monthly
Fortnightly

Wages – please specify Net* / Gross*

Net or Gross Wages You *

Net*
Gross*

Net or Gross Wages Partner *

Net*
Gross*

Maintenance / CSA Payment

You

Partner

Any Other Income / Benefits (specify)

You

Partner

Income Total

You

Partner

Joint Income Total

Expenses

Is this:

Weekly
Monthly

Total Expenses

Total Arrears (if any)

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List of Debts

Please include all debts and upload 2 months of bank statements and proof of income below. You may be asked for additional documentation once we have received your debt pack.

Debt List

Who is the money owed to?

Account Number

Amount Owed (if known)

Has this been passed to a collecting agent?

Name

Account Number

Please upload 2 months of bank statements & proof of income

Drag & Drop Files, Choose Files to Upload

Number of Debts

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