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Disability:
Please select...Not disabledDisabledPrefer not to say

Date of Birth (required):

Ethnicity—Please choose an option—White: EnglishWhite: ScottishWhite: WelshWhite: Northern IrishWhite: IrishWhite: Gypsy Or Irish TravellerWhite: OtherMixed: White & Black CaribbeanMixed: White & Black AfricanMixed: White & AsianMixed: OtherAsian Or Asian British: BangladeshiAsian Or Asian British: ChineseAsian Or Asian British: IndianAsian Or Asian British: PakistaniAsian Or Asian British: OtherBlack Or Black British: AfricanBlack Or Black British: CaribbeanBlack Or Black British: OtherOther: ArabOther: Any OtherPrefer Not To Say/Unknown

Health condition

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What benefits are you or a member of your household already claiming? (required):

What is the problem with your benefits? (required):

Circumstance (i.e. reasons for being on/claiming benefit – not working, low income, disability, children, housing, etc.) (required):

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What are the goods or services and what is wrong with them? (required):

When did you first find the goods or work was faulty? (required):

Where and when did you buy the goods/services? (required):

How were the goods paid for & do you have a receipt/credit agreement? (required):

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Roughly how much money do you owe? (required):

Do you have any rent/mortgage arrears/council tax/outstanding fuel bills? (required):

Are the debts in your name/joint names? (required):

Any savings or assets (e.g. Car valued over £1000)? (required):

How much can you afford to pay each week? (required):

Do you have a current bank account? (required): YesNo

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Are you:
Employed? (required): YesNo
Self-employed? (required): YesNo

I give my consent to the Citizens Advice holding information on my trade union status (required):
YesNo

Are you still working? (required): YesNo

If not, were you dismissed, made redundant, walked out, suspended?

How long have you been employed? (required):

Name of employer? (required):

Do you have a written contract? (required): YesNo

What has happened? (required):

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Are you: (required): MarriedIn a civil partnershipLiving together

How long have you been married, in a civil partnership, living together? (required):

What is your housing status: (required): RentMortgageJoint namesIn one name

Are there any emergencies, e.g. domestic violence, have nowhere to stay? (required): Please select...YesNo

Present situation, e.g. are you still living together? (required):

Are there any children involved? (required): YesNo
If so, what are their ages?

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Who is your current energy provider: (required):

Are you in debt with your current energy provider? (required): Please select...YesNo

Do you currently have electricity and gas available? (required): Please select...YesNo

What type of payment method are you using? (required): Please select...Direct DebitPay-paymentBank TransferOther

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Are you struggling with any household bills? (required): YesNo

Do you have a bank/Post Office account? (required): YesNo

Are you happy/confident searching for best deals i.e. energy/phones/insurance? (required): YesNo

Do you have any money issues preventing you from buying household essentials i.e. Food/energy/white goods? (required): YesNo

Are you confident with household budgeting? (required): YesNo

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Are you homeless, threatened with eviction or have to leave your home for another reason (e.g. domestic violence)? (required): YesNo

Is there an emergency, e.g. court dates, eviction notices, court warrants, threat of violence from somebody? (required): YesNo

If you have a tenancy:
Is it fixed term?YesNo
How long is the term?
Who is your landlord?
Do they live in the same property? (required): YesNo
Do you have any dependent children living with you? (required): YesNo

Housing benefit:
Are you receiving it? (required): YesNo
or
Have you applied for it? (required): YesNo

What is the problem with your housing? (required):

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Is the enquiry about: (required): YouYour partnerOther person

What is nationality of you/partner/other person? (required):

Full details of immigration enquiry: (required):

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Can you briefly describe what you want help with? (required):

Please enter other other other other other problems here, not