1. Client Name (Individual / Company) *

2. Contact Person (if company)

3. Email Address *

4. Telephone Number *

5. Client Address / Company Registered Address *

7. Full Name

9. Email Address (if known)

8. Residential Address (last known)

10. Registered Company Name

11. Company Number

12. Registered Office Address

I confirm the registered details match Companies House

13. Trading Address (if different)

14. Debtor Contact Email (if known)

15. Written Agreement / Contract? *
YesNo

16. Type of Agreement (if yes)
Written contractSigned terms & conditionsEmail agreementPurchase orderOther (please specify)

Other (please specify)

17. Date of Agreement / Contract

18. Governing Law (if known)
England & WalesOtherNot stated

If Other, specify

19. Total Amount Outstanding (£) *

20. Number of Invoices *

21. Invoice Details (optional — add up to 3, or upload invoices below)

22. Upload Supporting Documents (optional)
InvoicesContract / T&CsStatements of accountEmails / correspondence

Upload files (PDF/DOC/JPG/PNG) – max 10MB each

23. Reason(s) given for non-payment (if any)

24. Disputed in writing? *

YesNo

25. Debtor raised any of the following?
Service / goods disputeCounterclaimSet-offInsolvency threatNo response at all

26. Any part payments made? *

YesNo

If yes, amount and date(s)

27. How long has the debt been outstanding? *

Less than 30 days30–90 days3–6 months6–12 monthsOver 12 months

28. Minimum acceptable settlement (£) *

29. Accept instalments? *

YESNo

30. Instructions / sensitivities