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About You

First Name*
Surname*
Address

Town
County
Postcode
Postcode

Your Property (if applicable)

	Status
Property Value

Mortgage balance

Your History

Do you have any "adverse credit" i.e CCJs or defaults?

	Approx how much unsecured debt do you have?

	Collectively how much are your monthly payments?

	How many unsecured creditors do you have?

Contact Details

Daytime Tel*
Evening Tel
Mobile Tel
Email*
Best time to Contact

Additional Comments

If you require help in filling in this form please do not hesitate to contact us .

Conditions apply. Please note that repaying debt over an extended period may increase the total amount of debt to be repaid. Transferring debts to a financial management plan will affect your ability to obtain credit in the short term. Your ability to obtain credit may also be affected in the medium to long term. Dissolve Debt Ltd are fee charging financial management consultants licensed under the Consumer Credit Act 1974, Number: 563918

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Dissolve Debt, Suite C Kings Court, Railway Street, Altrincham, Cheshire, WA14 2RD, UK.