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Franchisee’s Name

Legal Documents Enclosed

Advisor’s Name
Partner Unaware

If different correspondence address to be used: Date DMA

Client’s Name

Client’s Name

Financial Services

Client Financial Planner

REV/10.05
1
APPLICANTS DETAILS
Financial Services First applicant Second applicant

Title Mr/Mrs/Ms/Other

Surname

Forename(s)

Date of Birth DD/MM/YY

Present address

Postcode Postcode

Telephone numbers (include all) Home Home


Work Ext Work Ext
Mobile Mobile
E-mail E-mail

Previous address if at current


address less than three years
Postcode Postcode

PROOF OF I.D.
Passport Number
Driving Licence Number
Other (Specify)
EMPLOYMENT DETAILS
Employers’s name
Employer‘s address

Postcode Postcode

Length of service (Give dates)


Position held/Job title
Payment Method
Payment Frequency

SELF EMPLOYED DETAILS


Dates
Occupation
BANK DETAILS
Name - ie Yorkshire Bank
Address

Postcode Postcode

Accounts held Current/Savings Loan/Mortgage Current/Savings Loan/Mortgage

STATUS
Marital Status Single Married Single Married
Separated Divorced Separated Divorced
Widow/er Living Together Widow/er Living Together

Number of Dependants and their ages


Number of Dependants Living at Home
and their ages
2
CAUSES/CIRCUMSTANCES LEADING TO CURRENT SITUATION

MONTH/YEAR EVENTS & CONSEQUENCES

MONTHLY INCOME
First applicant Second applicant

Net Wages/Salary (Current Average) £ p £ p

Job Seekers Allowance £ p £ p

Child Benefit/Single Parent Benefit £ p £ p

Working Tax Credit £ p £ p

Child Tax Credit £ p £ p

CSA/Child Maintenance £ p £ p

Income Support £ p £ p

Maternity Benefit £ p £ p

Incapacity/Sickness Benefit £ p £ p

Attendance Allowance £ p £ p

Pension £ p £ p

Employed Children/Relatives/Lodger £ p £ p

Financial Support (Family/Friends) £ p £ p

Other £ p £ p

INDIVIDUAL TOTALS £ p (A) £ p (B)

TOTAL FOR BOTH APPLICANTS = (A) + (B) = £ p (C)

3
MONTHLY HOUSEHOLD EXPENDITURE

Property Rent/Lodgings £ p
Arrears
Rent Arrears £ p Outstanding £ p

First Mortgage £ p
Arrears
Mortgage Arrears £ p Outstanding £ p
Arrears
Second Mortgage/Secured Borrowings £ p Outstanding £ p

Other Secured Borrowings £ p

Garage/Ground Rent £ p

Council Tax £ p
Arrears
Council Tax Arrears £ p Outstanding £ p
Arrears
Water Rates (including arrears) £ p Outstanding £ p
Arrears
Electricity (including arrears) £ p Outstanding £ p
Arrears
Gas/Oil/Solid Fuel (including arrears) £ p Outstanding £ p

Telephone £ p

Telephone - Cell/Mobile £ p £ p

Vehicle Hire Purchase/Rental £ p £ p


List Finance Company Name in Notes below
Other Hire Purchase/Rental £ p £ p
List Finance Company Name in Notes below
Child Maintenance/CSA £ p £ p

Child Minding Fees £ p £ p

School/Nursery Fees £ p £ p

School/Nursery Meals & Travel £ p £ p

Pension Contribution £ p £ p
Mortgage Linked?
Endowment Assurance £ p £ p
Mortgage Linked?
Whole Life Assurance £ p £ p
Mortgage Linked?
Term/Critical Illness Assurance £ p £ p
Mortgage Linked?
Payment Protection/ASU £ p

Buildings and Contents Insurance £ p

Pet Insurance £ p

Vehicle Insurance £ p £ p

Vehicle Road Tax £ p £ p

NI Contributions £ p

Union Fees £ p £ p

Opt/Dent/Med Expenses/Insurance £ p £ p

SUB TOTAL £ p £ p

Notes

4
MONTHLY HOUSEHOLD EXPENDITURE (cont)

SUB TOTAL CARRIED FORWARD £ p £ p

TV Licence £ p

Satellite/Cable Subscription £ p

Internet £ p £ p

Other 1 £ p £ p

Other 2 £ p £ p

Account Management Charge £ p

SUB TOTAL £ p (D) £ p (E)

Housekeeping - including Clothing £ p

Child Visitations £ p £ p

Travel by Public Transport £ p £ p

Vehicle Fuel - Monthly Mileage £ p £ p

Vehicle Maintenance £ p £ p

Vehicle MOT £ p £ p

Prescriptions £ p £ p

Special Needs Expenses £ p

Pet Food £ p

Leisure/Tobacco (specify in notes below) £ p £ p

Contingency £ p

IR/VAT (specify in notes below) £ p £ p

Court Fines £ p £ p

Other 1 £ p £ p

Other 2 £ p £ p

Other 3 £ p £ p

Other 4 £ p £ p

INDIVIDUAL TOTALS £ p (F) £ p (G)

TOTAL FOR BOTH APPLICANTS = (F) + (G) = £ p (H)

N ET M ONTHLY D ISPOSABLE I NCOME £ (C) MINUS £ (H) = £ p (J)

ACCOUNT MANAGEMENT £ p

MONTHLY PAYMENT TO EURODEBT £ p


(IF NOMINAL PAYMENT, DO NOT USE. ENTER PAYMENT ON NEXT PAGE)

Notes

5
CREDITORS
Action/ Start Date Current Contractual Next Monthly
Hold/ MM/YY Balance Monthly Payment
Creditor Collector (if different) Pending (Loans) Amount Inc. Arrears
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

TOTALS

SPECIAL INSTRUCTIONS REGARDING SPECIFIC CREDITORS


NO CREDITOR COURSE OF ACTION TO BE TAKEN

Monthly nominal amount clients can reasonably afford to offer their creditors. This
amount will be calculated and offered to their creditors on a proportionate basis.
(NOT TO BE USED IF THERE IS A MONTHLY DISPOSABLE INCOME)
minimum £85.00
Nominal monthly Amount Offered £ includes SPP fees

6
PROPERTY DETAILS
Mortgage, Rented or Lodgings

If Homeowners answer questions below

Date Purchased Purchase Price £

Open Market Value £

Forced Sale Value £

Less 1st Mortgage Outstanding Lender £

Less 2nd Mortgage Outstanding Lender £

Less Secured Borrowings Lender £

Less any arrears on mortgages or borrowings £ p

TOTAL PROPERTY ASSETS £ p

VEHICLE DETAILS
Make

Model/Engine

Year of Manufacture

If Hire Purchase or Conditional Sale


Name of Finance Company
Trade Value £ £

Less Total of Outstanding H-P payments (£ ) (£ )

INDIVIDUAL VEHICLE ASSETS £ £

TOTAL VEHICLE ASSETS £

FULL AND FINAL SETTLEMENT OFFERS


Should funds be available to the client to enable an offer of Full and
Final Settlement, please supply:-

The Source of Funding Note: Should the client wish to


proceed at any time, Head Office
must be notified in writing.
Amount of Funding

THIS SECTION TO BE SIGNED BY CLIENT(S) PRESENT AT MEETING


I/We confirm that the information provided by me/us is true and to the best of my knowledge.
Full name (printed) Signature Date
First applicant

Second applicant

Advisors Name

7
CALL REPORT CHECK LIST
Checked on
Item Enclosed Seen Bank Statement To Follow
Payslips (1)

1st Payment Due

Date of Meeting
Payslips (2)

Gas

Electric

Water

Council Tax

Mortgage

Rent
Telephone Number

H.P. Agreements

County Court P/W


Advisor

Current Creditors P/W

Payment
DMA Number

COMMENTS RE PAPERWORK:
FEE
Initial

Initial

DETAILS OF PAYMENT AS PER DMA:

DETAILS OF PAYMENT PROPOSAL AS PER DMA:


Last Name

Last Name

REMINDER: Please inform your clients that their file will be sent to Head Office for action.
All enquiries/correspondence should be forwarded to Head Office direct.
MAKE SURE THAT YOUR CLIENT IS AWARE THAT CONTACTING YOU
INSTEAD OF HEAD OFFICE COULD DELAY URGENT WORK ON THEIR CASE.