Personal Information Questionnaire Date:
Please complete this form and return it to us, at which point we will be able to assess your situation and decide upon
a suitable course of action.
Mr/Mrs/Miss/Ms Name Occupation
Home Tel. No. Mobile Tel. No.
Property Owned or Rented
If owned - solely or jointly? If owned - value - ? Mortgage amount outstanding - ?
Any other assets, such as other property, jewellery, investments, shares etc (please make clear type of asset and where possible provide a value)
Amount owed to creditors excluding mortgages ? Credit Cards (combined balance on cards, and monthly ? payments being made)
Bank debt (loan or overdraft outstanding) ? Personal creditors (personal or family loans etc) ? Please provide us with a brief history of how your debts arose…
? Monthly Salary (Net)
Regular Bonus/Overtime payments monthly (Net) ? Provide details of your partner’s monthly income (where ? you are living together)
? Total household monthly income
Please use amount from recent payments/invoices. If amounts are paid annually, show amount divided by 12 as a
Rent/Mortgage payment ?
Secured creditors ?
Council Tax ?
Water Rates ?
Telephone & Internet ?
Contents insurance ?
Buildings insurance ?
Television licence ?
Television rental ?
Sky TV ?
Food and housekeeping ?
School meals ?
Motor fuel (no of miles travel to work) ?
Car tax ?
Other travel expenses ?
Car insurance ?
EXPENDITURE INFORMATION (continued)
(continued) Car finance ? Car maintenance & AA/RAC cover ? Life assurance premiums ? Pension contributions ? Mobile phone ? Clothing ? CSA ? Prescription charges & contact lens/glasses ? Child care ? Private school fees ? Total Monthly Expenditure ? Net Monthly Surplus available (income less expenditure) ? Any other comments?
How would you prefer us to contact you in the future? Email Mail to home
(please state ‘yes’ in the correct box) address
Please complete this document and email it to firstname.lastname@example.org.
One of our corporate recovery specialists will then consider your case and respond
within 7 days.
Telephone: 0207 216 4601
Fax: 0207 628 3069
The UHY Hacker Young Group comprises separate and autonomous partnerships. 3
A member of UHY, an international association of independent accounting and consulting firms.