Name (Full name)

Email

Details of your debt enquiry (List of debts & amounts)

Phone Number

Date of Birth

Address

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How would you prefer to receive your welcome pack? (Tick one) How would you prefer to receive your welcome pack? (Tick one) via Email via Post

In order to send you the relevant Welcome Pack documents, please let us know if you receive Universal Credit. In order to send you the relevant Welcome Pack documents, please let us know if you receive Universal Credit. Yes No

In order to send you the relevant Welcome Pack documents, please let us know if you have any Health Conditions. (We need your explicit consent to store some information regarding your health conditions. If you agree, we'll use this information, which is known as 'special category personal data' to help progress your case. By ticking the box below, you consent to Citizens Advice Mid Lincolnshire storing the special category personal data that you have provided.) In order to send you the relevant Welcome Pack documents, please let us know if you have any Health Conditions. (We need your explicit consent to store some information regarding your health conditions. If you agree, we'll use this information, which is known as 'special category personal data' to help progress your case. By ticking the box below, you consent to Citizens Advice Mid Lincolnshire storing the special category personal data that you have provided.) Yes No