What type of debt is this? * Commercial (debtor is a business, sole trader, partnership, limited company or organisation) Consumer (debtor is a private individual whose current address is known) Consumer trace and collect (debtor is a private individual whose current address is not known)
Please confirm the legal status of the debtor * Limited Company (Ltd, Plc or LLP) Partnership (Non-Limited) Sole Trader Other (Organisation, Charity, etc.)
Debtor's Title (i.e. Mr, Mrs, Ms) *
Debtor's First Name *
Debtor's Last Name *
Is the same debt owed by more than one person, such as a husband, wife or partner? No Yes
Other Debtor's Title (i.e. Mr, Mrs, Ms) *
Other Debtor's First Name *
Other Debtor's Last Name *
Debtor's Address (including postcode) *
Debtor's last known address (including postcode) and date of birth, if known *
Debtor's normal trading address (including postcode) *
Contact names (and job titles, if known) *
Debtor's contact telephone numbers, e-mail addresses, etc *
Debt Currency £ (Pound Sterling) $ (US Dollar) € (Euros)
Debt Amount *
Do you have contractual terms in place which allow debt collection costs to be added to the debt? Yes No
Please provide details...
Has any part of the debt been outstanding for more than 12 months? Yes No
Has debt been disputed or been subject to litigation or action by a Solicitor, Collection Agency or other third party acting on your behalf (if so please provide further details)? Yes No
Details of dispute, litigation or action
Brief details of your claim (you can upload invoices, statements, etc below) *
Other comments or special instructions
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