Paid Work / Weekly / Monthly

(1)

Fi F in na an nc ci ia a l l P Pl la a nn n ne e r r F Fo or rm m

Your details

Account Number /s Daytime Telephone No:

(Please indicate the best time to contact you) Evening Telephone No:

(Please indicate the best time to contact you) Mobile Telephone No:

(Please indicate the best time to contact you) Work Telephone No:

(Please indicate the best time to contact you) No of Adults in the Household

No of Children (under 18) in the Household

Household Income Please include total amount received after any deductions ie: Tax and National Insurance.

Paid Work £ / Weekly £ / Monthly

Your take home pay

Your partner's take home pay Bonus / Overtime (Regular only) Retirement / Works Pension

Income Protection Insurance Payments Benefits

Job Seekers Allowance Income Support Tax Credits

Incapacity / Sickness / Disability Child Benefit

Other Income Investment Income

Please return completed form to: Collections Department Britannia

Britannia House Leek

ST13 5RG

Once you have completed the form please ensure you sign the declaration before returning. It is important that you provide us with accurate information so that we can help you to meet your commitments; please indicate either weekly, monthly or annual costs. We’re always here to help you, so if you have any questions, please contact us on 0845 121 0961.

(2)

Savings and Investments £ Balance Balance of Savings – easily accessible (Including Redundancy)

Value of other Investments (Property, Stocks & Shares)

Current Outgoings

In this section please tell us about all payments that you are currently committed to paying on a regular basis.

Property Costs (including 2nd properties)

Total Balance

Owed

£’s

Normal payment

£’s Arrears

Balance

£’s

Agreed Arrears Payment

£’s Monthly Weekly Monthly Annual

Mortgage n/a

Other Secured Loan(s) n/a

Endowment /Investment (to repay Mortgage) n/a

Rent / Mortgage on any other property _n/a

Council Tax

Ground Rent / Service Charge /Shared Ownership Rent

Utility Costs

Normal payment

Balance

£’s

Water

Gas

Electricity

Other household fuel

Insurance Costs

Normal payment

Balance

£’s

Life / Medical Insurance n/a

Mortgage / Income Payment Protection n/a

Vehicle Insurance / Breakdown Cover

Building & Contents Insurance

Pet Insurance

Travel Insurance

(3)

Travel Costs

Normal payment

£’s

Weekly Monthly Annual

Travel Expenses (Fuel / Parking / Fares) n/a

Vehicle Tax

Vehicle MOT / Servicing

Child Costs

Normal payment

£’s

Arrears Balance

£’s

Childcare n/a n/a n/a

Child Support Agency / Maintenance n/a

School Meals n/a n/a n/a

School Trips / Activities n/a n/a n/a

Children’s Pocket Money n/a n/a n/a

Healthcare Costs

Normal payment

£’s

Weekly Monthly Annual

Healthcare / Prescriptions n/a

Dental / Optical n/a

Other Costs

Owed

£’s

Normal payment

Balance

£’s

Magistrate Court Fines n/a

TV Licence n/a

Mobile Phone n/a

Telephone (Landline) n/a

Internet n/a

Satellite / Cable TV n/a

HP/Rental (Household Appliances) Housekeeping (Food / Toiletries /

Cleaning) n/a

Pet Food/Expenses (not Pet Insurance) n/a n/a n/a n/a

Meals at work n/a n/a n/a n/a

(4)

Other Costs (continued)

Owed

£’s

Normal payment

£’s

Socialising e.g. Cigarettes / Alcohol /

Lottery n/a n/a n/a n/a

Newspaper / Magazines / Subscriptions n/a n/a n/a n/a

Sundries & Emergencies n/a n/a n/a

Other (Incl. Pension Contributions) n/a n/a n/a

Other Arrears n/a n/a n/a n/a

Additional Information

Here we need to understand your other financial circumstances and help you to think about a repayment plan which will work for you and help you to get back on track with your finances.

Personal Finance Costs Total

Balance Owed

£’s

Normal payment

£’s

£’s Monthly

Name of Creditor Weekly Monthly Annual

Please use the space below to provide us with a background as to why you have been unable to meet your mortgage payments. We need to understand how your circumstances or situation has changed.

(5)

Useful Telephone Numbers

Britannia Collections 0845 121 0961

At Britannia, we are committed to providing a high level of customer service so if you have any further questions, please do not hesitate to contact us on 0845 121 0961. Our lines are open between 8am and 6pm Monday to Friday, and 8am to 1pm on Saturday. You will need your account number for reference. Telephone calls may be recorded and/

or monitored.

Britannia is a trading name of the Co-operative Bank Plc, authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

Useful Local Services – Numbers can be found in the phone book Citizens Advice Bureau: Advice on general matters and

welfare benefits

Money Advice Centres

Law Centre: Offer legal advice on a wide range of issues Trading Standards (Consumer Protection) Departments

Welfare Rights Advice Services Department of Work and Pensions Relate

This is an accurate record of my/our position at the date of signature.

I/We have fully understood the implications of non payment.

I/We understand that the information I/we have provided on this form will be retained with my mortgage account records on Britannia’s systems and will be used to assess my individual financial needs. I/We understand Britannia will not pass this information to any unauthorised third parties.

Signed by all parties to the mortgage:

Name: __________________________ Signature: __________________________ Date _____________________