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Address:
47 Cornfield Road,
Eastbourne,
East Sussex, BN21 4QN
DX: 6903 Eastbourne
Telephone: (01323) 412512
Fax: (01323) 411611
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Insolvency Online Form
Personal details:  
Title*:
Forename*:
Surname*:
House name/number
Street:
Town/city:
Postcode:
Landline number: Home Work

Mobile:
E-mail:
Preferred contact method: Post
  E-mail
  Landline - AM PM
  Mobile - AM PM
Employment details:
Employment status:
Occupation:
Income details (please provide monthly figures)
Net earnings:
Any other income (specify):
Total income:
Outgoings (please provide monthly figures. DO NOT INCLUDE DEBT REPAYMENTS)
Housing
Rent/mortgage:
Council tax:
Ground rent/service charges:
Mortgage protection premium:
Mortgage endowment:
Insurance premiums (buildings & contents):
Other (specify):
Utilities  
Gas/electricity/coal/ oil etc:
Water/sewerage:
Other (specify):
Household  
Food:
Telephone (mobile & landline):
Sundries (clothing, entertainment):
TV licence:
Other (Specify):
Motor/Travel  
Motor expenses (fuel, road tax, repairs etc)
Motor insurance:
Vehicle finance:
Any other outgoings (specify):
Total outgoings:
All Debts (totals only)  
Credit cards:
Unsecured Loans:
HP:
Friends & Family:
Overdrafts:
Other (specify):
Total all debts:
   
Are any of theses debts joint? yes no
If yes, provide details:
   
Assets  
Are you a homeowner? yes no
If yes, is it jointly-owned ? yes no
Other assets over £2,000 (specify):
General  
Have you ever been adjudged bankrupt?
Is someone petitioning for your bankruptcy?
Finally, how did you hear about us?
If Other, provide details:
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