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Forename(s)*
Surname*
Address line 1*
Address line 2
Address line 3
Town*
County*
Postcode*
Mobile Telephone No.
Main Telephone No.*
Email Address
Date of Birth*
Please give details of your enquiry:
Do you need help with any of the following?
What benefits are you and your family currently receiving?
Please tell us any key dates, such as the deadline for completing a claim form or the date of a decision that you wish to challenge:
How much are your debts in total?
Council Tax
Rent or mortgage
Gas or electricity
Court fines
Child support
Court Action
Bailiffs visiting
Disconnection of gas or electricity
Deductions from wage or benefits
Please tell us any key dates, such as the date of court hearings:
Please tell us any key dates, such as the date of future meetings with your employer or the date of your dismissal
What is your housing issue?
Please tell us any key dates, such as the date of court hearings or eviction:
What type of service is in dispute?
Do you have a disability or long-term health condition?
Please tell us any key dates or deadlines.
Please tell us any key dates or deadlines