UK-RESTART.CO.UK
INDIVIDUAL QUESTIONNAIRE
FULL NAME PREVIOUS NAME (if applicable) DATE OF BIRTH MARITAL STATUS RESIDENTIAL ADDRESS (inc. postcode) HOME TEL. NO. MOBILE TEL. NO EMAIL OCCUPATION EMPLOYED OR SELF EMPLOYED
SCHEDULE OF ASSETS (EXCLUDING VEHICLES AND PROPERTIES
ASSET SAVINGS Petty Cash Cash at Building Society SHARES PREMIUM BONDS ENDOWMENT POLICIES LIFE ASSURANCE POLICIES PENSION FUNDS OTHER DESCRIPTION & APPROXIMATE VALUE
HISTORY AND BACKGROUND The “History and Background” is an important part of the proposal and its purpose is to give the reader an overall picture of how your present circumstances have arisen. It should be ideally ¾ page of A4 paper and should include the following information: • Your name, where you live, and whether you are employed and for whom you work, or whether you are self-employed and the type of business you run. • Your marital status (married/single/co-habiting), and whether you have any children. • Your current home status i.e. Mortgage payer or renting, sole or joint. • If self-employed, when the business started, from where it traded, how it was financed and how trading went initially. If employed, a brief employment history and any relevant professional or academic qualifications obtained. A brief summary of what went wrong or the change in circumstances, including things that were beyond your control, such as bad debts, unforeseen items of expenditure, loss of a major contract, theft, vandalism, illness etc. It helps if the chain of events described is likely to provoke a sympathetic response from creditors. An explanation for each of your major liabilities should be given in as clear a manner as possible. History And Background
See attached
Signed:____________________________________________________________________ Name in block letters:_________________________________________________________ Date:______________________________________________________________________
MONTHLY PERSONAL INCOME AND EXPENDITURE SHEET
Full Name NUMBER OF CHILDREN/DEPENDANTS:
Monthly income Net wage after PAYE Drawings from business Spouses net wage Income support Family credit Pension Child benefit Child maintenance Non-Dependants Other Income please specify Total monthly income (A) Less:Monthly expenditure (B) Surplus (A-B) Amount available for creditors
Number of persons in Household
MONTHLY EXPENDITURE Mortgage 1 Mortgage 2 Rent Council Tax Water Rates House Contents insurance TV License Car HP Car Tax Car insurance Car Maintenance Life Insurance Housekeeping Traveling Costs School Meals Clothing Gas Electric Telephone Other expenses not mentioned Total monthly expenditure
£
Outstanding Court Actions
Name of Creditor Name of court How much is being claimed Type of action Dates of forthcoming hearings
Creditor List
Names of parties of whom you owe money to Joint or sole debt Amount Outstanding & reference number Solicitor/Debt collectors name address and reference and contact name
Asset Questionnaire Motor Vehicles Owned and used
Vehicle make & Model Finance company Reg: no Year of manufacture Engine Size Owner of vehicle Present Mileage Date of purchase
Asset Questionnaire Details of properties currently or previously owned or occupied
Address of property including postcode Freehold Leasehold/ Rented ETC Name(s) of owners /landlord and address Dates of entry/ acquisition Date property vacated Cost price Present value
(We need a recent valuation from an estate agent or valuer)
Value of mortgages/ charges/ unpaid rent
(Please provide statement)
Please check your answers thoroughly. Print off the application form and sign it where necessary. Then send to UK Restart, 2a Alton Chambers, 37 Church Road, Lower Parkstone, Poole BH14 8UJ. Or Fax to 01202 740608.