Name (Full name):

Date of Birth:

Email:

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

Phone Number:

Address:

Number of Adults:

Number of Bedrooms:

Number of Children:

Number of Vehicles owned:

Employment Status (Please tick one) Employment Status (Please tick one)CarerDisabled or SickGovernment work or Training SchemeIn full-time educationJobseekerLooking after the home or familyOtherPrefer not to sayRetired from paid workSelf EmployedSemi-retiredVolunteerWorking full-time (30 + hours per week), including temperarily off workWorking part-time (working between 16 to 29 hours a week) including temporarily off workWorking part-time (working less than 16 hours a week), including temporarily off work

Household Status (Please tick one) Household Status (Please tick one)CoupleCouple with dependent childrenCouple with non-dependent childrenOther Adults onlySingle personSingle person with dependent childrenSingle person with non dependent dependent childrenPrefer not to say

Housing Tenure (Please tick one) Housing Tenure (Please tick one)Prefer not to sayBuying it with the help of a mortgage or a loanLiving with family and paying rentOtherOwn outrightRent freeRent it from a local authority or housing associationRent it from a private landlordShared ownershipTemporary accomodationTied Accomodation

Please confirm that you are happy with our Privacy Notice stating that we'll collect and store any personal information you provide, but won't share it. Please confirm that you are happy with our Privacy Notice stating that we'll collect and store any personal information you provide, but won't share it. Yes, I am happy

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